NHSCSP AUDIT OF INVASIVE CERVICAL CANCER: NATIONAL … · 2019-10-03 · cancer (an estimated 9% of...

NHSCSP AUDIT OF INVASIVE CERVICAL CANCER:

NATIONAL REPORT 2009-2012

June 2013

NHSCSP audit of invasive cervical cancer: national report 2009-2012 i

June 2013

Lead Authors Professor Peter Sasieni Professor of Biostatistics and Cancer Epidemiology, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine Dr Alejandra Castanon Epidemiologist, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine

NHSCSP audit of invasive cervical cancer: national report 2009-2012 ii

June 2013

Document lnformation

Title NHSCSP audit of invasive cervical cancer: national report 2009-2012

Policy/document type Statistical reporting.

Electronic publication date

Version 1

Superseded publications None

Review date n/a

Author/s Peter Sasieni Alejandra Castanon

Owner Comments may be sent to Alejandra Castanon, [email protected], in readiness for review.

Document objective (clinical/healthcare/social questions covered)

Produced on behalf of the NHSCSP to report on the incidence of invasive cervical cancer 2009-2012, and to monitor the effectiveness of the NHSCSP.

Population affected All women eligible for the NHSCSP.

Target audience Programme Directors, policymakers.

Circulation list Web

Date Archived Current

NHSCSP audit of invasive cervical cancer: national report 2009-2012 iii

June 2013

CONTENTS ACKNOWLEDGEMENTS ..................................................................................................... 6 EXECUTIVE SUMMARY ...................................................................................................... 8 1. CONTEXT ....................................................................................................................... 10

1.1 The burden of cervical cancer in England ........................................................ 10

1.2 Epidemiology of HPV and cervical cancer ........................................................ 10

1.3 Cervical screening .............................................................................................. 10

1.4 HR-HPV DNA testing ........................................................................................... 11

1.5 Eligible age range and intervals for screening within the NHSCSP ................ 11

1.5.1 NHAIS ................................................................................................................ 12

1.6 Cervical screening and HPV vaccination .......................................................... 12

2. AUDIT OF INVASIVE CERVICAL CANCERS ................................................................ 14 2.1 Introduction ......................................................................................................... 14

2.2 Purpose of the audit ........................................................................................... 14

2.3 Audit Protocol ..................................................................................................... 14

2.3.1 Ethical approval ............................................................................................ 15

2.3.2 Selection of controls ............................................................................................ 15

2.3.3 Databases and other data sources ..................................................................... 15

2.3.3.1 Essential fields ................................................................................................. 16

2.3.3.2 Cytology screening history ............................................................................... 16

2.3.3.3 Colposcopy ...................................................................................................... 17

2.3.3.4 Cytology and histology reviews ........................................................................ 17

2.3.3.5 GP notes .......................................................................................................... 18

2.3.3.6 HR-HPV tests ................................................................................................... 18

2.3.3.7 Index of Multiple Deprivation ............................................................................ 18

2.3.4 Data aggregation .......................................................................................... 19

3. DATA COMPLETENESS AND LIMITATIONS ............................................................... 20 3.1 Cancers and population controls ...................................................................... 20

3.2 Dealing with missing values .............................................................................. 20

3.3 Cytology .............................................................................................................. 21

3.4 Colposcopy ......................................................................................................... 21

3.5 Histology ............................................................................................................. 21

3.6 HR-HPV DNA ....................................................................................................... 21

3.7 Treatment ............................................................................................................ 21

4. ANALYSIS AND COMMENTARY .................................................................................. 24 4.1 Invasive cervical cancer ..................................................................................... 24

4.2 Age at which invasive cervical cancer is diagnosed ........................................ 25

4.3 FIGO stage of invasive cervical cancers ........................................................... 26

4.4 Histology of invasive cervical cancers .............................................................. 31

NHSCSP audit of invasive cervical cancer: national report 2009-2012 iv

June 2013

4.5 Treatment of invasive cervical cancers ............................................................. 31

4.6 Cervical screening history (cases compared with controls) ........................... 33

4.6.1 Proportion of women never screened ........................................................... 33

4.7 Colposcopy ......................................................................................................... 36

5. Future developments/ Ongoing work .......................................................................... 40 REFERENCES ................................................................................................................... 41 GLOSSARY ........................................................................................................................ 43 Appendix A: Essential fields ........................................................................................... 44 Appendix B: Completion of data (essential fields) ......................................................... 45 Appendix Ci: List of Data Tables ..................................................................................... 50 Appendix Cii: Data tables ................................................................................................. 52

Table 1. Number of cases of invasive cervical cancer, 2009-2012, by audit year* and QARC .......................................................................................................................... 52

Table 2. Number and percentage of invasive cervical cancer in 2009-2012 audit in five-year age groups, by year of diagnosis .......................................................................... 53

Table 3. Number and percentage of invasive cervical cancer cases in 2009-2012 audit for each QARC region, by age ..................................................................................... 54

Table 4. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage*............................................................................................................ 55

Table 5. Number of invasive cervical cancer cases in 2009-2012 audit for each QARC region, by FIGO stage .................................................................................................. 55

Table 5a. FIGO stage of invasive cervical cancer cases in 2009-2012: estimated percent distribution, by QARC region ........................................................................... 56

Table 6. Number of invasive cervical cancer cases in 2009-2012 audit, by age and FIGO stage .................................................................................................................. 56

Table 6a. FIGO stage of invasive cervical cancer cases in 2009–2012 audit: estimated percentage distribution, by age-group .......................................................................... 56

Table 7. Number of invasive cervical cancer cases in 2009-2012 audit, by FIGO stage and year of diagnosis ................................................................................................... 56

Table 7a. FIGO stage of invasive cervical cancer cases: estimated percentage distribution, by year of diagnosis .................................................................................. 57

Table 8. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by histology .................................................................................................................. 57

Table 9. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by age at diagnosis and histology ................................................................................ 57

Table 10. Percentage of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage and histology ..................................................................................................... 58

Table 11. Number of invasive cervical cancer in 2009-2012 audit for each QARC region, by treatment ................................................................................................................. 58

Table 11a. Percentage of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by treatment .......................................................................................... 59

Table 12. Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by age at diagnosis and treatment ...................................................................... 60

Table 13. Number of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage and treatment ............................................................................................................... 61

NHSCSP audit of invasive cervical cancer: national report 2009-2012 v

June 2013

Table 13a. FIGO stage of invasive cervical cancer cases: estimated percentage distribution in 2009–2012 audit, by treatment ............................................................... 61

Table 14. Cervical screening status of invasive cervical cancer cases and controls aged 25-64, up to six months prior to diagnosis (percentages) ............................................. 62

Table 15. Cervical screening status of invasive cervical cancer cases and controls up to six months prior to diagnosis (numbers and percentages), by age ............................... 63

Table 16. Number and percentage of population controls (GP plus district controls) screened in the 3-5 year interval preceding the date of diagnosis of their matched case, by age .......................................................................................................................... 64

Table 16a. Number and percentage of population controls (GP plus district controls) screened in the 3-5 year interval preceding the date of diagnosis of their matched case ( aged 25-64), by QARC region ...................................................................................... 65

Table 17. Time to previous cytology among screened controls .................................... 66

Table 17a. Time to previous cytology test among potentially screen-detected* cases of cervical cancer and their screened controls ................................................................. 67

Table 18. Maximum interval between cytology tests (over the previous 8 years) among cases with FIGO stage 1B+ and their population controls ............................................ 68

Table 19. Number and percentage of invasive cervical cancer cases in 2009-2012 audit with colposcopic appointment recorded, by QARC region ............................................ 69

Table 20. Original cytology result by review result1 ...................................................... 70

NHSCSP audit of invasive cervical cancer: national report 2009-2012 6

June 2013

ACKNOWLEDGEMENTS

The authors are grateful to the following people for their comments and suggestions on earlier drafts of this report

• Members of the Cervical Screening Evaluation Group

o Julietta Patnick – NHS Cancer Screening Programmes o Monica Roche – Oxford Cancer Intelligence Unit o Richard French – East Midlands Cervical Screening QARC o Ruth Stubbs – North West Cervical Screening QARC o Nick Dudding – Sheffield Teaching Hospitals NHS Foundation Trust o Bryan Rose – Cervical Screening Wales o Simon Wrathall – East of England Screening, QARC o Eva Halloran - (representing lab QA group). o Penny Tidbury - (medical representative). o Hasit Patel – HBPC representative o Charles Redman - University Hospitals of North Staffordshire NHS Trust o Phil Bullock - Gloucestershire Hospitals NHS Foundation Trust

• QA Directors of the Quality Assurance Reference Centres.

A large number of individuals across England have worked diligently to collect the data presented here. It is impossible to name them all, but special thanks are due to the following:

• invasive cancer audit officers in the QARCs • Hospital Based Programme Coordinators • call and recall system managers • staff at cytology and histology laboratories • staff at colposcopy clinics.

Without their commitment and work this report would not have been possible. The authors also gratefully acknowledge research funding from Cancer Research UK (Grants C8162/A12537 and C8162/A10406). Professor Peter Sasieni Dr Alejandra Castanon


June 2013

PREFACE Since April 2007, the regional Quality Assurance Reference Centres (QARCs) in England have adopted a standardised protocol for capturing screening data on all cases of cervical cancer. The data are aggregated in a national database for the purpose of audit, with the aim of monitoring and improving the service. The first national audit report analysing these data appeared in July 2011, and covered cases of invasive cervical cancer diagnosed between April 2007 and March 2010. The second national audit report updated the data presented in the first, extended the period under scrutiny to March 2011, and covered both cytology and histology review data. This, the third national report, includes cases diagnosed between April 2009 and March 2012, presenting data on the most recently diagnosed cases only. We have therefore prioritised timeliness over data completeness, and readers should take note of the caveats attached to this approach. The data in this report are influenced by two wider changes. Firstly, data from April 2010 reflect a new policy (issued back in 2003, but implemented more recently) raising the age at which women are first invited for screening from 20 to 25. Since almost 50% of women are now screened for the first time within a few months of their 25th birthday, a small peak of screen-detected cancers at age 25 is observable. Secondly, the so-called ‘Jade Goody effect’ can be seen in the results, which show an increase in both cervical cytology testing and cancer diagnosis in late 2008 and early 2009, in the wake of the publicity surrounding the reality star’s diagnosis of cervical cancer (August 2008) and untimely death from the disease (March 2009). Finally, a word about the future. The ways in which the cervical screening programmes collect audit data, and the accuracy of those data, continue to improve. New audit guidelines, which will make the process more efficient and less time-consuming, were implemented in 2012 and will be reflected in the 2014 annual publication.

Professor Peter Sasieni Professor of Biostatistics and Cancer Epidemiology

Dr Alejandra Castanon Epidemiologist

Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine

NHSCSP audit of invasive cervical cancer: national report 2009-2012

June 2013

EXECUTIVE SUMMARY The NHS Cervical Screening Programme (NHS CSP) in England provides high-quality cervical screening to a target population of about 14 million women. The NHS CSP is highly effective in preventing cervical cancer, and still more effective in preventing death from the disease. • The NHS CSP audit comprises 10,920 women with confirmed diagnoses of cervical

cancer (an estimated 90% of all cervical cancers diagnosed between January 2007 and December 2010 in England).

• This report focuses on 6,508 women who had a confirmed diagnosis of cervical cancer between April 2009 and March 2012. They are compared to 12,841 women without cervical cancer.

• The proportion of missing staging data continues to decrease (from 13.3% in last year’s publication to 10.5%).

• The age at which cervical cancer is diagnosed in England has changed radically in the last 40 years: o In 1977, the observed rate per 100,000 observed in women aged 25-29 was 9.5

and in those age 30-34 it was 15.3, whereas by 1997 it had risen to 11.1 and 15.4 respectively. By 2010, the rate per 100,000 women aged 25-29 was 17.4, and 17.7 for women aged 30-34. Reasons for this change most likely include increases in underlying risk factors for cervical cancer (such as rates of SITs and smoking) and improvements in histopathological reporting of early stage cancer.

o The opposite is observed for incidence in women age 50-64: in 1977 they had rates of over 32 per 100,000, by in 1997 the rates were 13.4 per 100,000 and in 2010 rates were under 10. The decrease in rates in this age group is a direct result of screening: women are diagnosed and treated for pre cancerous disease preventing the development of cancer.

o Rates in women aged 20-24 have hardly changed over the years they were 2.5 in 1977, 2.8 in 1997 and 2.6 in 2010. Cervical cancer is rare in this age group (1.9% of cases in this audit) and screening is less effective. Now that women are no longer invited for screening till age 25 we expect rates to decrease in this age group, because some of the screen detected cancers at age 24 will now be screen detected at age 25. In fact a decrease in the proportion of cancers diagnosed in this age group is already apparent for the audit year 2011-2012 (Appendix C, Table 2) and a change in the stage at which cancers are diagnosed can also be seen (Section 4, Figure 4).

• Almost half (47%) of all the cases diagnosed in women aged 25-49 are micro-invasive cancers (stage 1A). 34% are stage 1B. However, in women aged 50 to 64, 50% of cancers are stage 2 or worse.

• Over 70% of stage 1A1 cancers were treated conservatively (by cone biopsy, loop excision or trachelectomy). In comparison, only 47% of stage 1A2 cases were treated conservatively.

• Since October 2009, a quarter of all women diagnosed between the ages of 25 and 34 were diagnosed at the age of 25. Between April 2007 and September 2009, just 8% of women within this same age range were diagnosed at 25. Sending women their first invitation to cervical screening at the age of 25 instead of 20 has therefore resulted in an increase in diagnoses of early stage cancer (1A) at age 25. However, there is no


June 2013

evidence to suggest that women who attend screening for the first time at the age of 25 have an increased risk of being diagnosed with stage 1B or worse cervical cancer.

• Despite improvements in histopathological reporting, women diagnosed with squamous carcinoma are more likely to be diagnosed when the cancer is at an early stage (40% of all squamous carcinoma was stage 1A) when compared to those diagnosed with adenocarcinoma (25% were diagnosed as stage 1A).

• The percentage of women with no cytology test (other than up to six months prior to diagnosis) is 27.4% for stage 1A cancer and 26.3% for stage 1B+ compared to only 13.3% in the population controls (Appendix C, Table 14). The proportion of women with no cytology test up to six months before diagnosis has increased substantially in those age 25-34 since October 2009 in both cases and controls (Figure 9).

• Nearly a third (21670/6508) women with cervical cancer did not have a cytology test indicating referral to colposcopy. At the other extreme 3% of cases had more than one referral to colposcopy (with at least two negative tests in between referrals) before diagnosis.

• Focusing on women with one referral to colposcopy before diagnosis and at least one colposcopy appointment recorded, we found the 77% are diagnosed within 4 months of the referring cytology. However 11% have a delay of 2 or more years between referral and diagnosis.

• Women with an interval of 2 years or more between referral and diagnosis are less likely to have been referred to colposcopy on a severe or worse cytological result and they are more likely to be diagnosed with stage 2 or worse cancer when compared to those with an interval of less than 2 years. Fortunately these women account for only 7% of all cancers in the audit.


June 2013

1. CONTEXT

1.1 The burden of cervical cancer in England Cervical cancer is a malignant neoplasm of the cervix uteri. In 2010, 2,305 cases were registered in England, with an incidence rate of 8.7 per 100,000 women (calculated using corresponding mid-year resident population).1 The highest incidence was among women aged 30–34 (17.7 per 100,000 women), followed by women aged 25–29 (17.4 per 100,000 women). The cervical cancer age-standardised incidence rate (world) for England in 2010 was 6.9 per 100,000, in 1975 it was 11.02 and for sub-Saharan Africa it was 31.7 per 100,000 in 2008.3 Thus it is reasonable to suggest that, in the absence of cervical screening, the age standardised incidence rate (world) would be between 11 and 32 cases per 100,000 women. Mortality from cervical cancer is substantially lower than incidence, with 830 deaths reported in 2009.4 Age-standardised relative survival for patients diagnosed from 2005 to 2009 was 83.6% at 1 year and 66.6% at 5 years.5 1.2 Epidemiology of HPV and cervical cancer Human papillomavirus (HPV) is a common, sexually transmitted infection. A small proportion of women who are infected with high-risk forms of this virus can go on to develop cervical cancer. There is consistent evidence from across the world that high-risk HPV (HR-HPV) infection is a necessary cause of cervical cancer, and optimal testing systems have identified the virus in all invasive specimens.6 HR-HPV is implicated in both squamous cell carcinoma (SCC) and adenocarcinoma (ADC), as well in over 95% cases of cervical intraepithelial neoplasia grade 3 (CIN3), which can subsequently develop into cancer. Cofactors that appear to increase the risk of developing cervical cancer in HPV-infected women include the use of oral contraceptives, smoking, high parity, unidentified genetic factors (possibly related to immunity), and previous exposure to other sexually transmitted diseases, such as Chlamydia trachomatis and herpes virus type 2. Women exposed to human immunodeficiency virus (HIV) are at elevated risk of HPV infection, HPV persistence, and cervical cancer. Cervical screening and treatment of high-grade CIN have the potential to prevent the development of cervical cancer in HPV-infected women, and screening programmes have therefore had a substantial impact on cervical cancer incidence in many countries.7 1.3 Cervical screening Cervical screening is not a test for cancer, but a means of preventing it. The English cervical screening programme uses cervical cytology and HPV testing to detect abnormalities which could lead to cancer if left untreated. Early treatment can prevent the development of almost 100% of cervical cancers.7 Though cervical screening sometimes does not detect an abnormality before the onset of cancer, it increases the chance of detecting asymptomatic disease at an early stage, which means that treatment is more straightforward and more likely to be successful. Virtually all micro-invasive (stage 1A) cancers are diagnosed by screening; these can often be treated with fertility-sparing surgery8, and can usually be cured (5 year survival >98%).


June 2013

The cytological screening test involves the collection, staining, and microscopic examination of cells from the cervix. Between 1988 and 2003, conventional smears were used to screen women: samples were taken from around the cervix and wiped onto a glass slide, which was then sent to the laboratory for examination. Between 2003 and 2008, a new way of preparing samples, known as liquid-based cytology (LBC) was introduced nationwide. Here, cells are brushed from the neck of the womb and placed into a small vial of preservative fluid. This is then sent to the laboratory, where a glass slide is prepared. The introduction of LBC has decreased the proportion of samples that are inadequate for evaluation, producing more representative specimens with less of the distracting background material that was found in conventional smears.9 1.4 HR-HPV DNA testing There are over 100 types of HPV, most of which do not cause significant disease in humans. However, around 15 types of HPV have been implicated in cervical cancer, notably types 16 and 18, which together give rise to some 70% of all cases. Research has shown that women with no evidence of HR-HPV infection are extremely unlikely to have concurrent precursor disease or cervical cancer, or to develop either for the following 6 years. 10

HR-HPV testing detects high-risk forms of HPV. Over the last few years, different uses for such tests have been under evaluation in England:

• to triage women whose cytology shows borderline changes or low-grade dyskaryosis, so that only those who are positive for HR-HPV are sent for further investigation.

• as a ’test of cure‘, to reduce the duration of surveillance following treatment for CIN by safely returning women to routine recall at an earlier date.

• to replace cytology as the primary screening test. As of April 2012, HR-HPV testing was introduced in England for triage and test of cure, following successful use at six sentinel sites within the NHSCSP. 1.5 Eligible age range and intervals for screening within the NHSCSP The NHSCSP aims to reduce the incidence of, and mortality from, invasive cervical cancer. It does this by regularly screening all women at risk, so that abnormalities that might otherwise develop into invasive cancer can be identified and treated. Cervical screening was introduced in England in the mid-1960s. By the mid-1980s, many women were undergoing regular cervical cytology, but there was concern that those at greatest risk were not being tested, and that those who had positive results were not being effectively followed up and treated. In response, the NHSCSP was established in 1988, after the Department of Health introduced quality standards for screening services and instructed all health authorities to introduce computerised ‘call and recall’ systems to manage invitations and results.

Between 1988 and 2003, women were invited for cervical screening at least every five years (and not more frequently than once every three years) from the age of 20 to the age of 64. In October 2003, it was announced that women would receive their first invitation five years later, at the age of 25, and that the interval between screening episodes would be three years up to the age of 49. Thereafter, women would be recalled every five years until the age of 64 (Table A). This remains current policy.


June 2013

However, while this alteration was announced in 2003, it was designed to take effect from the date of a woman’s next screening invitation. This meant that a woman screened prior to 2003 at the age of 20 had already been allocated a three-year recall, and could therefore have been invited again in 2006, despite the fact that she was still not 25. Similarly, a 61-year old women screened in 2003 could have been invited again three years later if her screening due date had been entered on the call and recall system before the change in policy. Moreover, in some parts of England, the policy change to a minimum age of 25 was not implemented until October 2005. It was therefore not until November 2010 that routine invitations to those aged 20-24 ceased. Today, all women between the ages of 25 and 64 are eligible for free cervical screening. However, because first invitations are sent out a few months before a woman’s 25th birthday, some women will still be screened at the age of 24. Cervical screening is not offered to women who have no cervix, or to those who have made an informed choice to opt out of the programme. Table A Cervical screening intervals since October 2003

Age group (years) Frequency of screening

25 First invitation.

25–49 Every 3 years.

50–64 Every 5 years.

65+ Routine screening for women who have not been screened since the age of 50, or who have had recent abnormal test results.

1.5.1 NHAIS All women aged between 25 and 64 and registered with a GP in England are eligible for cervical screening, including migrants. The process of calling and recalling women for screening is managed by a computer database called the National Health Authority Information System, or NHAIS (also known as ‘the Exeter system’). NHAIS manages the invitation process, keeps a record of test results, and, if all is well, recalls the woman for her next routine appointment in three or five years, depending on her age.

The programme screens almost four million women in England each year. In total, almost four and a half million samples per annum are examined by pathology laboratories (some women have more than one test, for clinical reasons or because a sample has proven to be inadequate).

While no cervical screening test can be 100% effective, cervical screening programmes greatly reduce the incidence of this cancer in the screened population. Since the establishment of the NHSCSP, the number of cervical cancer diagnoses has halved from 16 per 100,000 women in 1988 to 8 per 100,000 women in 2005, despite increasing rates of HPV infection. Another measure of the programme’s effectiveness is its coverage, defined as the percentage of women in the target age group (25–64) who have been adequately screened in the last five years. In 2011/2012, screening coverage of eligible women was 78.6%.11

1.6 Cervical screening and HPV vaccination


June 2013

Two prophylactic HPV vaccines are known to be effective at preventing both persistent HR-HPV infection, and the high-grade cellular abnormality (CIN3) that it can cause. In September 2008, a national HR-HPV immunisation programme was introduced to vaccinate girls against HPV 16 and 18. It covers young women aged 12–13, but also includes a catch-up programme for those born between 1990 and 1995. Despite this vaccination programme, the NHSCSP will continue to play an important role in the fight against cervical cancer. It will screen those women who have not been vaccinated, and it will also play a role in monitoring the vaccinated population because they are at risk of carrying non-vaccine HPV types and because vaccination in women that are already infected can fail. The role of the screening programme in these women can be better defined once clearer data are available about the cross-protection given by the vaccine for other HPV types, and the duration of the protection provided. Interim studies are needed to explore the impact of HPV vaccination, and to determine the best course of action for the cervical screening programme in future. A woman’s HPV vaccination status should be recorded on the call and recall computer system, so that her future screening interval can be determined. Unfortunately, the completeness with which this information is recorded is very variable, though ongoing work aims to simplify the process and improve the completeness and accuracy of the data.


June 2013

2. AUDIT OF INVASIVE CERVICAL CANCERS

2.1 Introduction Unfortunately, despite the effectiveness of population-based screening, women continue to develop cervical cancer. The reasons for this were recognised before the NHSCSP was established in 1988, and have been taken into account in previous recommendations emerging from this audit.12 Five-year cervical screening coverage has been around 80% since 1993, so the majority of cancers in England are probably occurring in women who have been screened at some point in their lives. Monitoring incidence and mortality rates in this population can determine whether the programme is achieving its objectives. It does not give a complete picture, however; nor does it indicate the effectiveness of the screening programme under optimal conditions. 2.2 Purpose of the audit The purpose of the NHSCSP audit of invasive cervical cancer (hereafter, ‘the audit’) is to monitor the effectiveness of the cervical screening programme, to identify areas of good practice and indicate where improvements might be made, and to monitor cases where the programme fails to prevent cervical cancer. The audit can also monitor whether alterations to the programme (for example, changes to the screening technologies employed, to the age range over which women are called for testing, and to the frequency of screening at different ages) are affecting the incidence of cervical cancer in the screened population. All cervical cancers are included in this audit, irrespective of their clinical stage, or the age of the woman at the time of diagnosis. The audit thus provides an early indicator of the pattern of disease incidence, using cases which have not necessarily been fully abstracted by the cancer registries. It allows the proportion of screen-detected cases to be determined, and explains why some cases occurred (e.g. diagnoses of cervical cancer in previously unscreened women, or cases that result from a failure of colposcopic treatment). Monitoring the effectiveness of the NHSCSP requires accurate data about the incidence of, prognosis for, and mortality from cervical cancer. Additionally, these data need to be linked to individual-level information about screening uptake and outcome. In order to obtain consistently reported information for this purpose, all parties in the NHSCSP were asked to follow the same national protocol for auditing cases of invasive cervical cancer.11 2.3 Audit Protocol Although there are minor differences in the procedure employed by different regions, the broad principles of the audit, including the allocation of key roles, are the same nationwide. These were first outlined in the document Audit of Invasive Cervical Cancers (NHSCSP publication no 28)12 and subsequently updated in April 201213 A further update was introduced in April 201314. These guidelines are currently being incorporated into an updated version of NHSCSP publication no 28, which will be published shortly. The NHSCSP Audit Management Group is the steering committee for the audit. Based on its data and findings, the Group approves updates and makes recommendations. In brief, when a case of histologically confirmed invasive cervical cancer has been identified, the clinician treating the woman must ensure that the Hospital-Based Programme


June 2013

Coordinator (HBPC) and the regional Quality Assurance Reference Centre (QARC) are informed. This will initiate a cascade of audit activities. The role of the HBPC is to organise audit activities locally (i.e. within each Trust). The role of the QARC is to ensure that local cytology, histology, and colposcopy review processes are coordinated according to the national audit protocol, and to liaise with Cancer Registries to ascertain that the information captured includes a record of the diagnostic status of each cancer case (though the extent of this cooperation varies between regions). The QARC also assembles all the data for a region, ready for national collation.

2.3.1 Ethical approval Anonymised data are routinely collected for women who have developed cervical cancer (known as ‘cases’) and for women of the same age who have not (known as ‘controls’). Since collection of these data is regarded as part of the NHSCSP’s service evaluation, the process is exempt from research ethics review by the National Research Ethics Service.15

2.3.2 Selection of controls

To permit rigorous evaluation of the programme, cases of cervical cancer are compared to controls of the same age. Controls are identified using bespoke software within NHAIS. All controls are registered with a GP in the same administrative district as the case, and women who are known to have had a hysterectomy are excluded. Additionally, controls fall into the following groups, based on their similarity with cases:

• GP controls, from the same group practice as the case. • District controls, who share the same first half of a postcode with the case, but who

are registered with a different GP. • Screened controls, who underwent cytological tests over roughly the same period as

the case (used where the case may have been diagnosed as a result of screening). • Abnormal controls, who received an abnormal cytology test report during roughly the

same period as the case. Each case is assigned two population controls (one GP control and one district control). In addition, some cases are assigned controls to match the woman’s screening history. This allows the audit of both cases that are detected by screening (known as ‘screen-detected cancers’), and cases where a woman received an abnormal screening result and was referred to a colposcopist some time before her actual diagnosis (see section 4.1). Population controls are used to study the importance of coverage and the efficacy of the screening programme. Screened controls are used to explore the impact of the screening interval on the incidence of screen-detected cancers. Abnormal controls are used to compare the way in which cases and controls are managed by the screening programme after a cytological test is reported as abnormal.

2.3.3 Databases and other data sources The audit is designed to collect data from a number of sources on a woman’s age, stage, and call and recall status, as well as on her cytology, colposcopy, and histology results. Information on a woman’s screening invitations and results, and laboratory data on her


June 2013

cytology, are drawn from NHAIS via Open Exeter.∗ Coordination between the HBPC and the QARCs is needed to obtain all other records, due to variability in the availability of data and level of access to the different databases. Colposcopy clinics are contacted for records of all appointments (e.g. information on patient attendance, details of the examiner, data on the colposcopic impression, account of any procedures performed). Histology results are also collated to produce a fuller picture, and to facilitate slide review. An audit database has been created to aggregate all data collected by regional QARCs for epidemiological analysis.

2.3.3.1 Essential fields To generate a minimum dataset, information about each case of cervical cancer is entered into the database via a number of essential fields (see Appendix A).

2.3.3.2 Cytology screening history Before 2003, cytology samples took the form of conventional smears, but between 2004 and 2008, laboratories converted to liquid-based cytology (LBC). To reflect the use of both technologies during the audit period, this document refers to cytology ‘tests’ or ‘samples’, not to ‘smears’. Details of every recorded cytology test for both cases and controls were downloaded from NHAIS. The dataset included a large number of privately-taken samples, as well as information on all NHSCSP tests. The following information was obtained:

• the date on which the test was taken. • the result of the test. • the action code resulting from the test.

(The action code is the national code used to define the woman’s recall type, the type of notifications required, and the period of time between recalls. It determines the management action for each woman in the light of her latest test result, and records any additional clinical input). Additionally, from April 2012, the following information is included in the NHAIS download:

• the interval between tests. • the date in which the woman’s next test is due. • the HR-HPV test result (where was an HR-HPV test was performed). • the reason a woman postponed screening (where appropriate). • the reason a woman was ceased from screening (where appropriate).

The following additional information is collected from NHAIS for cases:

• date of birth. • date of cancer diagnosis. • the FIGO stage of the tumour. • histology of the tumour. • treatment received (now an essential field). • the woman’s score according to an Index of Multiple Deprivation (now an essential

field). ∗ Open Exeter is a portal that allows bodies such as NHS trusts, GP practices, and laboratories to access the Exeter (NHAIS) system.


June 2013

For controls, date of birth and Index of Multiple Deprivation score were collected.

2.3.3.3 Colposcopy Colposcopy data were obtained for cases, including:

• date of appointment. • attendance at appointment. • whether the examination was satisfactory. • information on any surgical procedure(s) performed.

Non-essential additional fields included:

• colposcopic impression. • pathological diagnosis. • whether the woman was pregnant. • time to next follow-up appointment.

Colposcopy review guidelines and data collection forms were rolled out in April 2013. Results from this review should provide insight into colposcopic management in women who go on to be diagnosed with cervical cancer.

2.3.3.4 Cytology and histology reviews Audit guidelines covering the period of this report mandate that when a case of cervical cancer is confirmed, all cytology samples and histology specimens obtained over the 10 years preceding diagnosis, including those that led to diagnosis, must be reviewed. The primary purpose of this slide review is educational, and collated national results from this exercise, with detailed analysis and commentary, have been published separately.16 While some of these data are summarized here, those interested in obtaining a more detailed picture should refer to the published document. Data obtained from the review process include:

• date of the original sample or specimen. • date of the review. • type of reviewer (screener, checker, advanced practitioner, consultant). • original sample or specimen result. • result of the review/consensus.

Following the implementation of revised guidelines in April 2012, fewer slides need to be reviewed and, in the case of cytology, fewer reviews per slide as required. This will result in a significant reduction in workload, as diagnostic biopsies, which currently form 78% of histology reviews (4,780 out of 6,122 reviews) will not form part of future audits. The introduction of the new audit guidelines was followed by a 3 month period (April to June 2012) where reviews of cytology and histology samples from women diagnosed with cervical cancer as part of audit were suspended. As a result, the number of reviews submitted for this publication has barely changed from last year and the new data is insufficient to present on its own. Therefore, no review results will be presented this year; however a full report on the first year of the new guidelines will be presented in next year’s report. For details on the review results please refer to the Audit report for 2007-2010.


June 2013

2.3.3.5 GP notes Following a recent review by the West Midlands QARC, the Evaluation Committee has agreed that, in most cases, it is not possible systematically to collect useful information from this source. Consequently, information derived from GP notes is no longer required as part of this audit. However, it may be of interest to collect information from GP notes where a woman’s screening history is unclear. This may yield additional information on her symptoms (if the cancer is symptomatic), and may also explain any non-attendance at appointments (e.g. where there is evidence of pregnancy, travel, co-morbidity, or private treatment). There are currently several other projects exploring the possibility of obtaining information from GP notes. The Evaluation Committee will evaluate the results from these projects and assess whether there is a feasible way to obtain data from this source before revising the audit protocol.

2.3.3.6 HR-HPV tests HR-HPV DNA is currently being introduced nationally as part of the NHSCSP, following evaluation at three pilot and six Sentinel Sites. It is used for two purposes:

1. To triage of women with low-grade or borderline cytology reports. Where HR-HPV is found, these women are referred immediately to colposcopy, but where women are HR-HPV-negative, they are returned to routine (three- or five-yearly) recall.

2. As a ‘test of cure’ for women who have been treated for cervical intraepithelial neoplasia (CIN). If a cytology test, taken six months after treatment, is reported as normal, borderline, or low-grade, an HR-HPV test is performed. Women who are HR-HPV-negative are returned to routine recall, but those who are HR-HPV-positive are referred to colposcopy. (Women with high-grade cytology six months after treatment are referred immediately to colposcopy, without this additional HR-HPV test).

HR-HPV test results are currently recorded on NHAIS and have been added to the list of essential fields.

2.3.3.7 Index of Multiple Deprivation The Office of the Deputy Prime Minister produces the English Indices of Deprivation, from which the Index of Multiple Deprivation, utilized by this audit, is derived.∗ For the purpose of this exercise, the index of deprivation has been divided into deciles, from the most deprived (0) to the least (9). The Index of Multiple Deprivation score is derived from each woman’s postcode. To facilitate the collection of this field, the woman’s home postcode is now captured as part of the NHAIS download and converted automatically by the audit database into a deciles. Only the deprivation deciles are collected nationally. However, because this data field is currently not essential, it has not been reported consistently across QARCs. The data received to date, while quite revealing, are therefore incomplete (see Appendix B, Table 1a). Since 2012 this field is essential and more detailed analysis will be possible in future.

∗ For more information see https://www.gov.uk/government/publications/english-indices-of-deprivation-2010-technical-report.


June 2013

2.3.4 Data aggregation Names, addresses, and unique identifiers (such as NHS numbers) are deleted before data are transferred to the national audit database. The only data that might be considered “person-identifiable” received by the audit is date of birth. However, since there are 750 women in England between the ages of 20 and 65 with any given date of birth, this information is considered insufficient to identify a particular individual, effectively making the data anonymous.


June 2013

3. DATA COMPLETENESS AND LIMITATIONS

The findings presented in this report should be approached in light of the available information’s varying degree of completeness (see Appendix B). The difficulties involved in ensuring the completeness of essential data fields are described below. It is rare for data to be reported as missing, but missing data should be distinguished from incompleteness of record. Missing data may be unavailable (e.g. where a death certificate, which does not provide information about cancer staging, has been used), or may not yet have been recorded as part of the audit. For this reason, the term ‘none recorded’ has been used to cover both scenarios, although reference is also made to ‘missing values’. Other cases may be subject to reporting delays, having been submitted to the audit before all essential fields could be completed. In these instances, missing fields are updated as and when data become available, with the result that complete information may not be received for some months after the case has been registered. An additional challenge, which can create further delay, is the need to coordinate between the various aspects of the audit process when a case of cervical cancer is diagnosed. In future, as the completeness of the audit for each case will be monitored, it will be possible to distinguish between data that are not available (after reasonable efforts have been made to collect them) and data that have not yet been collected (see Appendix B). 3.1 Cancers and population controls Cases of cervical cancer are identified by NHS hospital staff (primarily via gynae-oncology), and confirmed by histology. A small proportion of cancers will be missed by the audit, and a very small proportion will be excluded because the patients are not registered with an NHS GP. Table D (Section 4.1) illustrates the limited extent of this problem, comparing the number of registrations for cervical cancer in a given calendar year with the number of cases picked up by the audit over the same period of time. Controls are selected randomly (subject to matching) from women registered with an NHS GP. All those selected are included in the audit. 3.2 Dealing with missing values Cases reported by the MB1 series (Cancer registration statistics in England) between 2008 and 2010 were compared to those recorded in the audit for the same period by age at diagnosis to explore whether missing values (in particular those for FIGO stage) are related to the age at which the cancer is diagnosed or the FIGO stage at diagnosis. The aim was to ascertain whether there is a subset of women for whom a delay in the inclusion of the cancer in the audit is more likely (see Table C). The number of cases in the audit for 208-2010 is 92% of the number of cervical cancer registrations in England over the same three years. However, the data are more likely to include cases diagnosed in women between the ages of 25 and 64 (96% of all registered cancers), than in women over the age of 65 (74% of registered cancers). We also assessed the completeness of the data for FIGO stage by comparing the distribution of staged cancers diagnosed between April 2008 and March 2009 across four audit years (Table D). Women with a cancer of unknown stage and those whose case was not registered into the audit straight away were more likely to have been diagnosed with stage 2 or worse cancer. For instance, looking at cancers diagnosed in April 2008 to March


June 2013

2009, 23% of those registered by October 2009 were stage 2 or worse, but by October 2012 30% were stage 2 or worse. In previous reports, we assumed that data for FIGO staging was missing at random. In recent audits, this has led to an overestimation of the proportion of stage 1A cancers and an underestimation of the proportion of stage 2+ cancers. This bias applies to figures that present stage distribution over time. However, results shown in Table E (Section 4.1) suggest that, in recent years, cancers have been registered into the audit in a timelier manner. If this trend continues, the bias in the stage distribution should diminish year on year. For this report we have used a more complicated model that takes into account the differential delays in obtaining stage1. 3.3 Cytology Since data for cytological tests are downloaded directly from NHAIS, completeness is assumed for all cases and controls. This is because cytological test results are recorded for all women who participate in the NHSCSP, and for some of those who are tested privately. The audit does not attempt to capture screening events that take place outside the UK. 3.4 Colposcopy The quality and completeness of the colposcopic data are variable. This is principally because there is no central database to act as a repository for this information (indeed, most colposcopy records were not computerised until 2001). It is therefore difficult to determine where a woman attended for colposcopy, particularly if she visited more than one clinic. The best indicator of whether a woman is likely to have had colposcopy is the presence of a ‘suspend’ code in her cytology record (see Table 19). Similarly, a record from the histology laboratory would suggest that a sample was taken at colposcopy. However, neither the cytology nor the histology record provides conclusive information regarding colposcopic examination. 3.5 Histology The quality and completeness of the data on histology in this audit are also variable, as there is no national link between histology laboratories. The proportion of histological samples reviewed in the audit is based on the total number of samples recorded in the database, rather than the total number of histological samples taken within the NHSCSP. 3.6 HR-HPV DNA Data on HR-HPV testing are now being collected directly from NHAIS in conjunction with the cytology data. We expect to be able to report on this in coming years. 3.7 Treatment

1 For each QARC, a multinomial logistic regression model was fitted with outcome ‘stage at diagnosis’ and explanatory variables age group, treatment type and year of diagnosis. Using the results of this model, the probability of each stage category was then predicted for each individual with missing stage


June 2013

Data on treatment are obtained by the HBPC from patient notes or from the meeting notes of the multidisciplinary team (MDT). These fields tend to be provided as data become available, which may mean that the information is missing for a few months after cases are first entered in the audit. Obtaining treatment data can be especially challenging where women are diagnosed in one centre and treated in another. There has been some confusion over the use of the category ‘none’ to report treatment. The intended meaning is that the treating hospital has given only palliative care, but at least one QARC interpreted the category as ‘no treatment was reported’. Additionally, some HBPCs used ‘none’ when micro-invasive cancers were treated solely with the diagnostic LLETZ/cone biopsy. While efforts have been made to correct this miscommunication for the future, some cases classified as ‘none’ in the audit may, in fact, have received treatment. From 2011 onwards, we are able to distinguish between ‘palliative care’ and ‘no treatment’.


June 2013

Table B Cancers reported nationally compared to those reported in the Audit between January 2008 and December 2010. Total cases

reported <20 20-24 25-29 30-34 35-39 40-44 45-49 50-55 55-59 60-64 65-69 70-74 75-79 80-84

85 and over Total

Aged 25-64

MB1 series

2008/10 2 147 963 980 1,006 841 609 465 432 418 300 319 306 294 304 7,386 5,714

Audit 2008/10 1 143 997 969 992 829 580 401 376 362 264 242 227 217 178 6,778 5,506

Proportion 50.0% 97.3% 103.5% 98.9% 98.6% 98.6% 95.2% 86.2% 87.0% 86.6% 88.0% 75.9% 74.2% 73.8% 58.6% 91.8% 96.4% Difference 1 4 -34 11 14 12 29 64 56 56 36 77 79 77 126 608 208 Table C Cancers in women aged 20-64 diagnosed between April 2008 and March 2009

Data received as of

Observed stage by year of audit data Proportion of those with stage

recorded

1A 1B 2 3+ 1B+ None

recorded Total % 1A %1B %2+ Oct-09 463 380 130 109 67 419 1,568 40.30% 36.70% 23.10% Oct-10 646 598 239 201 82 398 2,164 36.60% 36.50% 26.90% Oct-11 665 651 275 241 90 283 2,205 34.60% 36.50% 28.90% Oct-12 669 659 295 259 93 277 2,252 33.90% 35.90% 30.20%


June 2013

4. ANALYSIS AND COMMENTARY

This section analyses and discusses the audit’s key findings. Detailed data tables are presented in Appendix C. 4.1 Invasive cervical cancer Over the period 2007–2012, 10,920 cases of invasive cervical cancer and 21,581 controls were included in the audit. Table D (see also Table B, section 3.2) provides a broad assessment of the audit’s coverage, comparing the number of cases of invasive cervical cancer included in each audit year (corresponding to the financial year) with the number reported nationally in each calendar year. Although some cases included in the audit are not included in Cancer Registry data, and vice versa, the number of cancers reported to registries is only around 9% greater than the number included here. Updated estimates from the Office for National Statistics (ONS) report 2,766 diagnoses of invasive cervical cancer during 2009 and 2,346 during 2010, whereas the audit comprises 2,452 cases during 2009-10 and 2,087 during 2010-11.17 All QARCs are working to minimise these discrepancies and to make both data sources more directly comparable. Table D also presents a recent history of the number of cervical cancers included in each audit year. We have included this to illustrate the amount of new data received each year. Compared to national registrations, 72% of cancers diagnosed between April 2009 and March 2010 had been reported into the audit by October 2010, rising to 85% by October 2011 and 89% by October 2012. By comparison, 80% of cancers diagnosed between April 2010 and March 2011 had been reported into the audit by October 2011 and 89% by October 2012. These numbers suggest that data are being entered into the audit in an increasingly timely manner. However, there is a trade-off between presenting data in a timely manner and the completeness of that same data. We have emphasized timeliness, and this year’s report includes a great deal of detail on when we receive the data and how this timing affects our estimates of FIGO stage and age at diagnosis (see Section 3.1). Additionally, we focus only on the most recently diagnosed cervical cancers by restricting the data in this report to 6,508 cases diagnosed between April 2009 and March 2012 and their 12,841 controls (see table E). However where relevant, we have used all cancers reported to the audit. Table D Number of cases of cervical cancer included in this report compared with those reported nationally

Audit Year Calendar

year

Cases included in 2010 report

Cases included in 2011 report

No of cases in this Audit

report Cancer

Registrations£ 2007-2008 2007 2,089 2,136 2,158 2337 2008-2009 2008 2,164 2,205 2,254 2409 2009-2010 2009 1,978 2,349 2,452 2766 2010-2011 2010 0 1,876 2,087 2346 2011-2012 2011 0 0 1,969 2511 Total 10,920 12369

£ Source: We have used updated number of registrations from Table 8 of the Office for National Statistics MB1 publication 42 (2011). As with the audit, ONS receive notification of a few extra cancers after they have published their yearly statistics.


June 2013

Most cases submitted to the audit have at least two age-matched population controls (GP and district). However, for a small number of cases (23), only one of these controls was identified (see Table E), while 76 cases were submitted with no population control. For a defined subset of cases, up to two further controls were selected, resulting in 3,084 screened controls and 3,784 abnormal controls (see section 2.4.3.1.) Table E Number of cases of invasive cervical cancer and controls submitted to the 2009–2012 audit by QARC regiona

QARC Case

Two Population Controls (GP and District)

One Population Control (GP or

District)

No Population Controls

East of England 618 617 0 1 East Midlands 660 652 6 2 London 622 544 6 72 North East 425 424 1 0 Yorkshire 763 760 3 0 North West 831 829 2 0 South Central 495 494 1 0 South East Coast 510 509 1 0 South West 762 761 1 0 West Midlands 822 819 2 1 Total 6508 6409 23 76 *Cancers diagnosed 01/04/09 to 31/03/2012

4.2 Age at which invasive cervical cancer is diagnosed Figure 1 shows the percentage distribution of cases of cervical cancer by age in the 2009–2012 audit, compared to the numbers reported nationally for 2007-2010. The peak number of cases is observed in the 25–29 year old age group (1,037 or 15.9%), followed closely by cases in women aged 30-34 (888 or 13.6%), and aged 35-39 (819 or 12.6%). Nationally, the peak incidence is observed in those aged 35-39, followed by those aged 30-34. The underreporting of cases to the audit increases with the age of diagnosis, so that we are missing more cases for women over the age of 65 than for those under age 65. 82% of all cases of invasive cervical cancer in this audit fell within the age group eligible for cervical screening (25-64 years, see Table 3, Appendix C). In 2010, women in this age group made up 78% of all cervical cancer registrations in England. As a proportion of all cancers, invasive cervical cancer at FIGO stage 2 or worse was more likely to be diagnosed in women over the age of 50 than in those under 50, with stage 1A disease becoming increasingly infrequent with age. By contrast, between the ages of 25 and 49, the majority of women diagnosed with cervical cancer were found to have stage 1A or 1B disease (see Table 6a, Appendix C). The difference in the stage at diagnosis by age is even more apparent when looking at rates of cervical cancer (Figure 2). We used the observed rates of cervical cancer by age group reported in the MB1 series in 2010 and applied the FIGO stage distribution observed in the audit dataset. The age at which cervical cancer is diagnosed in England has changed radically in the last 40 years. For example in 1977 the rate per 100,000 observed in women aged 25-29 was 9.5 and in those age 30-34 was 15.3, by 1997 these had increased to 11.1 and 15.4 respectively.2 In 2010 the rate in women aged 25-29 was 17.4 and 17.7 in women aged 30-34. Reasons for this dramatic change in cancer rates include increases in


June 2013

underlying risk factors for cervical cancer (such as rates of SITs and smoking) and improvements in histopathological reporting of early stage cancer. The opposite is observed for incidence in women age 50-64: in 1977 they had rates of over 32 per 100,000, in 1997 the rates were 13.4 per 100,00 and by 2010 rates were under 10 per 100,000 women.2 We believe that changes in cancer rates in this age group are a direct result of cervical screening. Indeed the effect screening has had on all age groups can be seen by the reduction of over 70% in mortality from the disease due to prevention of cervical cancer and earlier stage at diagnosis. Rates in women aged 20-24 have hardly changed over the years, they were 2.5 in 1977, 2.8 in 1997 and 2.6 in 2010.2 Cervical cancer is rare in this age group (1.9% of cases in this audit) and screening is less effective in this age group when compared to older women. We are keen to identify any changes in the FIGO stage of cancers diagnosed aged 25-29 as a result of the change in screening policy. It is too early to show any results in this report, but we continue to monitor the situation and will report on any changes in subsequent reports.

4.3 FIGO stage of invasive cervical cancers Table F shows the observed number of cervical cancer cases by FIGO stage for each QARC region. FIGO stage information is missing for 9.33% of cases and clinical staging was not possible for 1.14% of women, therefore no staging data is available for 10.5% of cases (see Appendix B, Table 1b). The distinction between cases with missing stage data and cases where clinical staging was not possible is a recent one. It is difficult to determine the true proportion of cancers where staging is not possible, but we could speculate that it is similar to the proportion with missing histological data on type, i.e. 3.5% of cases (see Table 8, Appendix C). The proportion of cases with missing stage has been reduced by a third since the first audit report was published (from 17% to 11% in this report), but we now know that those cancers where the FIGO stage is unknown tend to turn out to be higher stage than those with known stage. Therefore, we estimate that had all the cancers been staged, 35% of cancers in the audit would be stage 1A, 32% stage 1B, and 33% stage 2 or worse (Table G). In 1,293 out of 2,167 cases of 1A cancer, further details were provided, and these suggest that 92% are 1A1 and only 8% 1A2 (see Table 4, Appendix C). 89% of women with stage 1A1 cancer were aged between 25 and 49, while only 1.3% were over the age of 65. Similarly in 949 out of 1896 cases of 1B cancer, further details were provided, and these suggest that 88% are 1B1 and 12% are 1B2.

Figure 3 shows the percentage distribution of invasive cervical cancer by FIGO stage and by age group in those women with a known FIGO stage. As the age of women increases, the proportion of cases diagnosed as FIGO stage 1A decreases, and the proportion of women diagnosed at FIGO stage 2+ increases. Stage 1A cancer is often screen-detected, and treatment generally has fewer side effects and is more likely to be curative. The large proportion of cervical cancer cases diagnosed at stage 1A (particularly those at stage 1A1) in women under the age of 50 can be regarded as a benefit of the screening programme. The exception is women aged <25. As fewer women under the age of 25 attend screening due to the raising of the lower age limit for the programme, the likelihood of screen-detected cancer in this group decreases. Therefore, it is mostly those women who are investigated because of symptoms who are likely to be diagnosed at this age.


June 2013

Figure 4 shows the estimated percentage distribution of cervical cancer cases by FIGO stage, year of diagnosis, and age. Estimates for the last two years of data included in the audit are dotted, as this more recent data is less complete and we are less certain of the accuracy of the results. The effect of raising the age at which women are first invited for screening from 20 to 25 can be clearly seen from 2009 onwards. 65% of women in the audit were diagnosed between the age of 25 and 49. 46% of these women are diagnosed with stage 1A cancer and a further 36% with stage 1B cancer. The ‘Jade Goody effect’ (a rise in the number of younger women attending cervical screening appointments following the diagnosis and untimely death of the reality TV star) can also be seen in an increase in the number of stage 1A cancers diagnosed in this age group in 2009. Women over the age of 50 at diagnosis, and particularly those diagnosed after the age of 65, are more likely to be diagnosed with advanced stage cancer than younger women. There has been no discernible change in the stage distribution for these women since the audit began in 2007. Figure 1 FIGO stage of cervical cancer cases: estimated percentage distribution, by age

0

200

400

600

800

1000

1200

20-24 25-29 30-34 35-39 40-44 45-49 50-55 55-59 60-64 65-69 70-74 75-79 80-84 85+

FIGO Stage 2+ FIGO Stage 1B FIGO Stage 1A

147

963980 1,006

841

609

465432 418

300 319 306 294 304

Reported nationally 2008/10

Num

ber o

f cas

es


June 2013

Figure 2 Observed 2010 rates per 100,000 women: by FIGO stage of cervical cancer cases and age

Figure 3 FIGO stage of cervical cancer cases: percentage distribution, by age-group

0

2

4

6

8

10

12

14

16

18

20

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Rat

es p

er 1

00,0

00

FIGO Stage 2+ FIGO Stage 1B FIGO Stage 1A

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<25 25-49 50-64 65+Age at diagnosis

1A1 1A2 1B1 1B2 2+


June 2013

Figure 4 FIGO stage of cervical cancers cases: estimated percentage distribution by financial year

a) Diagnosed age <25 b) Diagnosed age 25 to 49

FIGO stage

c) Diagnosed age 50-64 d) Diagnosed age 65+

0

10

20

30

40

50

60

70

2007/08 2008/09 2009/10 2010/11 2011/12

Prop

ortio

n

Year of diagnosis

0

10

20

30

40

50

60

70

2007/08 2008/09 2009/10 2010/11 2011/12

Prop

ortio

n

Year of diagnosis

0

10

20

30

40

50

60

70

2007/08 2008/09 2009/10 2010/11 2011/12

Prop

ortio

n

Year of diagnosis1A 1B 2+

0

10

20

30

40

50

60

70

2007/08 2008/09 2009/10 2010/11 2011/12

Prop

ortio

n

Year of diagnosis


June 2013

Table F Number of cervical cancer cases by FIGO stage in 2009-2012 audit, by QARC region

QARC Region 1A 1B 2+ 1B(NOS)* None recorded Total East of England 196 32% 205 33% 170 28% 4 1% 43 7% 618 100% East Midlands 241 37% 197 30% 111 17% 2 0% 109 17% 660 100% London 202 32% 162 26% 182 29% 52 8% 24 4% 622 100% North East 139 33% 124 29% 51 12% 73 17% 38 9% 425 100% Yorkshire and the Humber 318 42% 184 24% 67 9% 28 4% 166 22% 763 100% North West 259 31% 252 30% 103 12% 89 11% 128 15% 831 100% South Central 178 36% 153 31% 134 27% 1 0% 29 6% 495 100% South East Coast 180 35% 164 32% 116 23% 12 2% 38 7% 510 100% South West 239 31% 239 31% 235 31% 28 4% 21 3% 762 100% West Midlands 215 26% 216 26% 306 37% 0 0% 85 10% 822 100%

Total 2,167 33% 1,896 29% 1,475 23% 289 4% 681 10.5% 6,508 100% * Cases reported as 1B(NOS) ( are known to be stage 1B or worse but detailed stage is not known)

Table G Estimated percent distribution of cervical cancer cases by FIGO stage in 2009-2012 audit, by QARC region

QARC Region 1A 1B 2+ Total East of England 32% 37% 31% 100% East Midlands 38% 32% 30% 100% London 35% 27% 38% 100% North East 36% 34% 29% 100% Yorkshire and the Humber 45% 30% 25% 100% North West 33% 37% 30% 100% South Central 36% 32% 31% 100% South East Coast 37% 35% 28% 100% South West 32% 33% 35% 100% West Midlands 27% 28% 45% 100%

Total 35% 32% 33% 100%


June 2013

4.4 Histology of invasive cervical cancers Figure 5 shows the distribution of invasive cervical cancer cases by histological type. Most of the cases of cervical cancer show squamous histology (72%), while 20% are adenocarcinomas. Adenosquamous types are significantly rarer. Squamous carcinoma is more likely to be diagnosed as stage 1A cancer than the other histological types: 40% were stage 1A compared to 25% of adenocarcinoma and 9% of adenosquamous cases. Over half of the cases with undifferentiated or other histological types were diagnosed as stage 2 or worse. Figure 5 Percentage of cervical cancer cases, by histology

4.5 Treatment of invasive cervical cancers Figure 6 shows the distribution of treatment for cervical cancers, according to age (see also Table 12). The most aggressive treatment employed in each case has been captured. Treatment was recorded in 4,394 cases (68%) (Table 11), and out of those, the most common treatment was cone biopsy/loop excision/trachelectomy (32.6%), followed by simple or radical hysterectomy (25.6%), and radiotherapy plus chemotherapy ± hysterectomy (25.2%). Only 2.4% of those treated by cone biopsy/loop excision/trachelectomy had a trachelectomy. 4% of treatments were recorded as ‘none’. Filtering the results by age reveals that for women aged 50 to 64, the most common treatment was chemotherapy plus radiotherapy ± hysterectomy (42%), followed by hysterectomy alone (27%). By contrast, 45% of women under 50 had fertility-sparing treatment (cone biospy/loop excision or trachelectomy) with only 29% undergoing a hysterectomy (simple or radical). For those aged 65 to 79, chemotherapy plus radiotherapy ± hysterectomy (41%) was the most common treatment, followed by radiotherapy ± hysterectomy (24%). However, 14% of women in this age group reportedly received no treatment, other than perhaps palliative care. Given the substantially poorer relative survival of elderly cervical cancer patients nationally,18 this appears to warrant further investigation. It should be borne in mind, however, that some regions may have recorded ‘no treatment’ because they were unable to find a record of treatment, rather than because the patient was not treated (see section 3.7).

0 10 20 30 40 50 60 70 80

Squam

Adeno

Adeno-Sq

Undifferentiated

Other

Unknown

FIGO stage 1A FIGO stage 1B FIGO stage 2+

71.9%

19.5%

2.8%

3.5%

1.8%

0.5%


June 2013

Figure 6 Percentage treatment of cervical cancer cases, by age at diagnosis

Figure 7 shows the distribution of treatment for invasive cervical cancer by stage of disease. The graph reveals that the majority of women diagnosed with FIGO stage 1A1 cancer received cone biopsy/loop excision (74%), whereas those with stage 1A2 are more likely to have non-fertility preserving treatment (52%). Women with stage 1B1 cancer were most likely to have had a simple or radical hysterectomy (54%), whereas those with stage 1B2 were more likely to have chemotherapy plus radiotherapy ± hysterectomy (53%). The majority of those with stage 2 or worse (57%) cancer received chemotherapy plus radiotherapy ± hysterectomy. Note that a very small proportion (1%) of cancers diagnosed at stage 1A1 are recorded as having been treated with chemotherapy plus radiotherapy ± hysterectomy. Similarly, 1% of stage 2 or worse cancers are recorded as having a cone biopsy. These are clearly misclassifications of stage and/or treatment which we are endeavouring to correct for the future.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

20-49 50-64 65+Age at diagnosis

None

Chemo plus radio ± hyst

Chemo ± hyst

Radio ± hyst

Hysterectomy

Trachelectomy

Cone biopsy


June 2013

Figure 7 Percentage treatment of cervical cancer cases by FIGO stage

4.6 Cervical screening history (cases compared with controls)

4.6.1 Proportion of women never screened Figure 8 shows the proportion of cases and controls with no recorded screening history up to six months prior to diagnosis in women aged 25 or older. 681 cases are excluded because no information on stage was available. The data show that controls were generally more likely than cases to have attended screening previously. Note that we have excluded 46 women aged 65 or over with FIGO stage 1A cancer because the lack of routine screening for women in this age group means that it is unlikely that these cancers were screen-detected. Instead, this small number of cancers (46 out of 1033 in women aged over 65) may represent rare instances of incidental cancer diagnosis. The proportion of women with invasive cervical cancer and no cytology tests (other than within 6 months of diagnosis) has remained constant for all age groups since the audit started, except for women aged 25–34. Figure 9 shows the proportion of cases and controls aged 25-34 by screening history over two time periods (April 2007-September 2009 and October 2009-March 2012). The data reveal that the proportion of women whose screening history is up to date has not changed over time, whereas the proportion of women with no screening history before diagnosis (those who have ‘never’ been screened) has almost doubled and the number of women who are lapsed attenders has decreased. This change is due to the fact that a large proportion of women are now being diagnosed as a result of their first smear at age 25 (25% of all cases diagnosed between October 2009 and March 2012 aged 25-34 had their first smear at age 25, compared to 8% before October 2009). Table H presents the odds ratios of developing cancer for women who have never been screened, compared to those who attend screening as recommended, by diagnosis period.

0

10

20

30

40

50

60

70

80

90

100

1A1 1A2 1B1 1B2 2+FIGO Stage

None

Chemo-radio+/-hyst

Chemo+/-hyst

Radiot+/-hyst

Hysterectomy

Trachelectomy

Cone biopsy


June 2013

The risk of being diagnosed with cervical cancer is significantly increased for women who have never been screened across all age groups, compared with that for women who have attended regularly. For cancers diagnosed in women over the age of 35 there is no difference in the odds ratio between the two diagnosis periods (April 2007-September 2009 and October 2009-March 2012). However, for women aged 25-34, the odds ratio of being diagnosed with stage 1A cancer among those who had not previously been screened compared to those that attend regularly was much greater after September 2009. This difference in the odds ratio was not observed for stage 1B or worse cancers. The results presented in this section suggest an increase in the number of women diagnosed aged 25-34 with stage 1A cancer and no previous screening history most likely due to the fact that women get invited for screening at the age of 25. Although the proportion of women with no prior screening history has increased since October 2009 among those diagnosed with stage 1B cancer, the results do not suggest that that odds of developing 1B or worse cancer among women who have not been previously screened compared to those screened regularly has changed between periods. It should be noted that we cannot yet assess the full impact of the change in policy until all the women diagnosed with cancer age 25-34 are invited for screening at age 25. Currently all women aged 28-34 were invited from age 20. Figure 8 Proportion of women with no screening test (other than those taken within six months of diagnosis), by FIGO stage and age.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

25-34 35-49 50-64 65+

Age

FIGO stage 1A

FIGO stage 1B+

Population controls


June 2013

Figure 9 Screening history of women diagnosed aged 25-34 and their controls, by FIGO stage and diagnosis period.

Table H Odds ratio of cervical cancer diagnosis in women with no history of cervical screening compared to those attending screening as recommended (i.e. every 3 or 5 years), by diagnosis period

Age FIGO stage

Diagnosed April 2007 to September 2009

Diagnosed October 2009 to March 2012

OR 95% CI OR 95% CI

25-34 1A 1.96 (1.52-2.53) 3.42 (2.68-4.35) 1B+ 2.95 (2.25-3.87) 2.59 (1.98-3.40)

35-49 1A 4.17 (2.91-5.97) 4.24 (2.89-6.23) 1B+ 7.46 (5.64-9.87) 8.25 (6.18-11.01)

50-64 1A 5.33 (2.76-10.27) 6.02 (2.94-12.35) 1B+ 12.93 (9.10-18.38) 13.51 (9.45-19.33)

27 28

55

24 29

53

51 44

24

3332

15

2228

21

43 3932

0

10

20

30

40

50

60

70

80

90

100

Stage 1A Stage 1B+ Control Stage 1A Stage 1B+ Control

Diagnosed Apr07 to Sep09 Diagnosed Oct09 to March12

Screened upto date Screened lapsed Never


June 2013

4.7 Colposcopy Collecting colposcopy data for this audit has been challenging, and the variability of the available information has made interpretation still more difficult. However, data on colposcopic history are of particular importance where there is an interval of four months or more between cytology results that indicate referral and subsequent diagnosis. This is because the interval indicates either a delay in administering the diagnostic procedure (attributable to the woman or her service provider), or the recurrence of a previously-treated cervical abnormality. Out of the 6508 cervical cancer cases in the audit, 31% (1,985) do not have a cytology test indicating referral to colposcopy. 175 of the 4523 (69%) women with at least one referral to colposcopy before diagnosis had the referring cytology on the same date as a colposcopy or on the date of diagnosis. These women were considered not to have been referred before diagnosis, because the data suggest that the cytology was taken at colposcopy and therefore it does not represent a screening opportunity. The majority of women in the dataset 64% (4,133) have one cytology test indicating referral to colposcopy, 3.2% have more than one referral to colposcopy2 (assumed to be in long term follow-up for previous cervical abnormality) and 33% (2,152) have no referrals to colposcopy. A summary of those referred to colposcopy can be found in Table 19. Of those with one referral to colposcopy: 77.6% were referred on a severe or worse cytology, 9.4% on a moderate, 4.8% on a mild, 7.4% on a borderline, 0.5% on a negative and 0.3% on an inadequate test. No colposcopy information was available for 37% of women with one referral to colposcopy and the completeness of the colposcopy data we do have is uncertain. We found a higher proportion of women with no recorded colposcopy were referred two or more years before diagnosis (16%) when compared to those for whom we do have colposcopy information (11%). However the proportion diagnosed within 4 months was the same (76% vs. 77%) and no difference between the groups was observed in terms of the result of their referring cytology; suggesting this is purely a data capture issue. Therefore we will only present detailed results for women with at least one colposcopic appointment recorded in the dataset (n=2,606). A summary of the intervals between referral and diagnosis, referral and colposcopy and colposcopy to diagnosis in women with one referral recorded is presented in Table I. Overall the majority (77%) of women with one referral to colposcopy are diagnosed within 4 months of the abnormal cytology; however 11% have a delay in diagnosis of 2 years or more. Among those with a recorded colposcopy appointment before diagnosis (n=2606), the longer the interval between referral and diagnosis the less likely it is that the woman was referred with a severe or worse test (see Figure 10). Furthermore when the referral to colposcopy occurred 2 or more years before diagnosis the cancer is less likely to be diagnosed as FIGO stage 1A and much more likely to be diagnosed as FIGO stage 2 or worse (see Figure 11). To assess the colposcopy history of those women for whom a delay in diagnosis is suspected we will focus on those women with a delay of more than 4 months between referral and diagnosis, they represent 23% (605/2606) of all women for whom we have colposcopy. Colposcopy history for women with a diagnosis more than 4 months after 2 A new referral episode is only counted when a woman has at least two negative cytology tests between tests with an action code of suspend


June 2013

referral by the time from referral to diagnosis is presented in Table J. The first thing to note about the table is the proportion of women for whom we only have a colposcopy within 2 months of diagnosis. For 32% of the women in this table the only colposcopy appointment recorded is the one where the diagnosis of cancer was made. Information on the colposcopy where the diagnosis was made is relatively easy to obtain. As the time between diagnosis and colposcopy increases it becomes harder to obtain information about the colposcopy visit. Indeed 40% of those diagnosed more than 2 years after referral only have a colposcopy within 2 months of diagnosis. We are unable to say in such cases whether there was a lack of failsafe (i.e. the women did not attend), colposcopy failure (i.e. the woman attended earlier and was discharged without treatment) or whether it was treatment failure. Most of the women (41%) for whom the delay in diagnosis was less than a year after referral have had an appointment where a punch biopsy revealed CIN2 or worse and 5% were treated at least once before diagnosis. However when the delay is between 12 and 23 months we see that 24% either did not have a punch biopsy on their first colposcopy or the results of the punch biopsy was normal and 16% were treated (unsuccessfully) on the first colposcopy. A further 20% were diagnosed with CIN2 or worse on a punch biopsy, but their diagnosis was still delayed over a year. The data are insufficient to identify exactly what lead to the delay in diagnosis. However it is clear that having a delay of two or more years between suspected abnormalities on your cervical test and diagnosis may have an impact on the stage at which your cancer is diagnosed. However there is also evidence that these cancers may be harder to identify, as the referral cytology was less likely to be severe. We do not have the data to further ascertain whether the delays are in the patients themselves or provider delays. Fortunately delays in diagnosis of two years or more represent a small proportion of all cases of cervical cancer, approximately 7% ( i.e. 11% of those with one referral to colposcopy (4133) = 455, 455/6508= 6.9%).


June 2013

Table I Summary of the intervals between referral and diagnosis, referral and colposcopy and colposcopy to diagnosis in women with one cytology indicating referral to colposcopy and at least one colposcopy recorded in the dataset

Women with one cytology indicating referral to colposcopy and a

recorded colposcopy1

Time from referral to diagnosis2

Time from referral to first colposcopy

Time from first colposcopy to diagnosis

N % N % N %

0-3.99 months 2001 77% 2336 90% 2279 88% 4-6.99 months 123 5% 50 2% 35 1% 7-11.99 months 102 4% 33 1% 74 3% 12-23.99 months 99 4% 26 1% 76 3% 24+ months 281 11% 161 6% 138 5% Total 2606 100% 2606 100% 2602 100%

1There was no colposcopy appointment recorded for 1524 (37%) women 2Note that very similar proportions were observed among women with at least one referral to colposcopy but no recorded colposcopy with the exception of a larger proportion of women (16%) being diagnosed more than 2 years after referral. Figure 10 Result of the referring cytology by time from diagnosis, in those with a recorded colposcopy

0

10

20

30

40

50

60

70

80

90

<4mth 4mth-11mth 12mth-23mth 24mth+

Perc

enta

ge

Negative/Inadequate

Bord

Mild

Mod

Severe or worse


June 2013

Figure 11 FIGO stage by time from the first recorded cytology indicating referral to colposcopy and diagnosis

Table J Colposcopy history in women with a diagnosis more than 4 months after referral, by time from referral to diagnosis 4-11mth 12-23mth 24mth or more Total

N % N % N % N %

No record (except within 2 months of diagnosis)

43 35% 37 18% 111 40% 191 32%

DNA 6 5% 13 6% 18 6% 37 6% Colp normal/No biopsy on first colposcopy after referral

11 9% 48 24% 43 15% 102 17%

Punch biopsy (or unknown procedure) with a diagnosis of <CIN2 6 5% 30 15% 35 12% 71 12% CIN2+ 51 41% 41 20% 32 11% 124 20%

Treatment 6 5% 32 16% 42 15% 80 13% Total 123 100% 201 100% 281 100% 605 100%

0

10

20

30

40

50

60

70

80

<4mth 4mth-11mth 12mth-23mth 24mth+

Perc

enta

ge

FIGO stage 1A FIGO stage 1B FIGO stage 2 or worse


June 2013

5. FUTURE DEVELOPMENTS/ ONGOING WORK

Results from this audit are presented to the Advisory Group, and changes will be implemented as part of the screening programme where appropriate. This audit forms the basis for a number of peer-reviewed articles. The following manuscripts are either under peer review or have very recently been accepted for publication and should be widely available over the next few months: (i) harms and benefits of screening from age 20 when compared to screening from age 25, (ii) the degree of protection offered by screening women who are over the age of 65, (iii) How much could primary human papillomavirus testing reduce cervical cancer incidence and morbidity (J Med Screen) and (iv) characteristics and screening history of women diagnosed with cervical cancer age 20-29 (BJC). Over the next 12 months we will use the data to analyse: (i) the impact of the ‘Jade Goody effect’ on the diagnosis of cervical cancer within the screening programme, (ii) comparison of different screening history classifications and (iii) the risk of developing cervical cancer following a cytology test taken as part of the screening programme. The audit management group have updated the audit guidelines in order to make the review process more efficient and to enhance its educational focus. It is too soon to report on the outcomes of these changes but we continue to monitor the situation. The colposcopy review process will continue to be improved as part of future audit protocol documents. In the longer term, the audit database will be integrated into the new national cancer registry for England, which will increase capacity to store and manage information on each registration. This will enable screening history to be related to mortality allowing us to study survival.


June 2013

REFERENCES

1. Cancer Statistics – Registrations, England, 2010. Series MB1 no 41. London: Office for National Statistics. Available at http://www.ons.gov.uk/ons/datasets-and-tables/index.html?pageSize=50&sortBy=none&sortDirection=none&newquery=MB1+series. Accessed 20 Nov 2012. 2. Statistics prepared by Cancer Research UK, using data from Office for National Statistics. Cancer Statistics: Registrations Series MB1. Available at: http://www.ons.gov.uk/ons/search/index.html?newquery=series+mb1 3. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://globocan.iarc.fr, accessed on day/month/year. 4. Mortality Statistics: Deaths Registered in England and Wales (Series DR), 2009. London: Office for National Statistics, 2010. Available at http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-199137. Accessed 05 Dec 2011. 5. Cancer Survival in England- Patients Diagnosed 2005-2009 and followed up to 2010. London: Office for National Statistics, 2011. Available at http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-239726. Accessed 05 Dec 2011. 6. The Aetiology of Cervical Cancer (NHSCSP Publication No 22). Sheffield: NHSCSP, 2005. 7. Cervix Cancer Screening (IARC Handbooks of Cancer Prevention, 10). Lyon: IARC Working Group on the Evaluation of Cancer-Preventive Strategies, 2005. 8. Kosary C L. Cancer of the Cervix Uteri. In: Ries L A G, Young J L et al. (eds). SEER Survival Monograph: Cancer Survival Among Adults: US SEER Program, 1988–2001, Patient and Tumor Characteristics. Bethesda, MD: National Cancer Institute SEER Program, 2007. 9. Karnon J, Peters J, Platt J et al. Liquid-based cytology in cervical screening: an updated rapid and systematic review and economic analysis. Health Technology Assessment, 2004, 8(20): iii, 1–78. 8. 10. Dillner J, Rebolj M, Birembaut P et al. Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening: Joint European Cohort Study. BMJ, 2008: 337, a1754. 11. Cervical Screening Programme, England: 2011–12. Sheffield: NHSCSP and London: The NHS Information Centre, 20121. Available at http://www.ic.nhs.uk/statistics-and-data-collections/screening/cervical-screening. Accessed 13 Dec 2012. 12. Audit of Invasive Cervical Cancers (NHSCSP Publication No 28). Sheffield: NHSCSP, 2006. 13. Protocol Changes to the Audit of Invasive Cervical Cancers 2012-13. Sheffield: NHSCSP, 2012. http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp28.html 14. Protocol changes to the audit of invasive cervical cancers: to be implemented April 2013. Addendum to NHSCSP Publication No 28. Sheffiled: NHSCSP 2013.

http://www.ons.gov.uk/ons/datasets-and-tables/index.html?pageSize=50&sortBy=none&sortDirection=none&newquery=MB1+series

http://www.ons.gov.uk/ons/datasets-and-tables/index.html?pageSize=50&sortBy=none&sortDirection=none&newquery=MB1+series

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-199137

http://www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-239726

http://www.ic.nhs.uk/statistics-and-data-collections/screening/cervical-screening

http://www.ic.nhs.uk/statistics-and-data-collections/screening/cervical-screening

http://www.cancerscreening.nhs.uk/cervical/publications/nhscsp28.html


June 2013

15. Defining Research. National Research Ethics Service, Dec 2009. Available at NRES - Is your project research?. Accessed 22 June 2011. 16. Castanon A, Ferryman S, Patnick J, et al. Review of cytology and histopathology as part of the NHS Cervical Screening Programme audit of invasive cervical cancers. Cytopathology, 2012 23(1): 13-22. 17. Cancer Statistics – Registrations for Cancer Diagnosed in 2011, England. Series MB1 no 42. London: Office of National Statistics, 2013. Available at http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/index.html. Accessed 03 Jul 2013. 18. CANCERSTATS: Cancer survival statistics by age, 2009. London: Cancer Research UK. Available at http://info.cancerresearchuk.org/cancerstats/survival/age/. Accessed 11 May 2011.

http://www.nres.npsa.nhs.uk/applications/is-your-project-research

http://www.nres.npsa.nhs.uk/applications/is-your-project-research

http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/index.html

http://www.ons.gov.uk/ons/rel/vsob1/cancer-statistics-registrations--england--series-mb1-/no--42--2011/index.html

http://info.cancerresearchuk.org/cancerstats/survival/age/


June 2013

GLOSSARY

Action code This field (downloaded as part of the screening history from NHAIS)

denotes the action to be taken in response to the result of each cytology test. The codes are: A. Routine screening/call and recall.

H. Result recorded, but no change in current action code. (This code is normally used when privately-taken cytology tests are entered into the system).

R. Early recall at an interval specified by the laboratory. S. Suspend recall pending referral.

Cases Women diagnosed with invasive cervical cancer in England.

Controls Women who have not been diagnosed with cervical cancer, who are registered with a GP in England. They are matched by age and place of residence with a case.

Cervical Screening Evaluation Group /Audit Management Group

The group charged with evaluating developments in the NHS Cervical Screening Programme. The CSEG oversaw the NHS CSP national audit until February 2011, when an Audit Management Group was established, consisting of a subgroup of individuals from the Evaluation Group. The new Audit Management Group is charged with coordinating the development of audit protocols, and with gathering and disseminating recommendations for best practice

Confidence Interval Confidence interval is a term used in inferential statistics that measures the

probability that a population parameter will fall between two set values. The confidence interval can take any number of probabilities, with the most common being 95% or 99%.

Exeter call and recall system

The system used to invite women for screening. Since 1988, it has stored screening records for all women registered with a GP

FIGO stage The cancer staging classification developed by the International Federation

of Gynaecological Oncologists (I, IA, IA1, IA2, IB, IB1, IB2,III, IIIA, IIIA, IV, IVA, IVB).

Hospital Based Programme Coordinators (HBPC)

The named individual within each NHS trust who is responsible for collating cases of invasive cervical cancer and initiating the audit process.

Quality Assurance Reference Centres (QARC)

The nine Quality Assurance Reference Centres (QARCs) in England are responsible for the quality of the screening programme in their area. With the exception of the North East and Yorkshire and The Humber QARCs, each covers one region of the country.


June 2013

APPENDIX A: ESSENTIAL FIELDS

SECTION A & A1 Personal details NHS number (to be held locally)

Date of birth For cases only:

Date of diagnosis Stage of tumour (FIGO) Histology

Treatment Index of Multiple Deprivation SECTION B Cytology Reason for no cytology

Date test was taken Result of cytology test HPV result

SECTION C Colposcopy For cases only: Number of colposcopic appointments Date of colposcopy Attendance type Colposcopist Surgical procedure

SECTION C2 Colposcopy review All fields should be completed

SECTION D1 Histology cancer diagnosis

For cases only: Date of specimen Type of specimen Pathological diagnosis FIGO stage

SECTION D2 Specimen history Date of specimen Type of specimen Pathological diagnosis Excision status

SECTION E Cytology Review of cases

E1. Original slide Slide ID Cytology type Date of original test Original test result

E2. Review results Reviewed location Review result Original result NFR (no further review)

SECTION F Histology Review of cases

F1. Original specimen Specimen ID Date of original specimen Pathological diagnosis Evidence of TZ sampling

F2. Review results Reviewed at Review pathological diagnosis Excision status


June 2013

APPENDIX B: COMPLETION OF DATA (ESSENTIAL FIELDS)

NHS Number is not received nationally B-1 Proportion of essential data collected for cases in Section A. Personal and cancer details Section A: Essential fields

Date of Birth

Date of Diagnosis Stage* Histology*

QARC Region Case n % n % n % n % East of England 618 618 100 618 100 580 93.9 617 99.8 East Midlands 660 660 100 660 100 552 83.6 630 95.5 London 622 622 100 622 100 598 96.1 605 97.3 North East 425 425 100 425 100 387 91.1 419 98.6 Yorkshire and the Humber 763 763 100 763 100 598 78.4 717 94.0 North West 831 831 100 831 100 703 84.6 829 99.8 South Central 495 495 100 495 100 471 95.2 472 95.4 South East Coast 510 510 100 510 100 477 93.5 468 91.8 South West 762 762 100 762 100 751 98.6 760 99.7 West Midlands 822 822 100 822 100 784 95.4 819 99.6 Total 6508 6508 100 6508 100 5901 90.7 6336 97.4 *Cases where data collection is complete and stage is missing are considered to be staged as a reasonable amount of effort has been made to collect the data. Incomplete cases with a stage recorded as X (or missing) are considered not to have stage. Please refer to section 6 for full details regarding missing data


June 2013

B-1a Proportion of non-essential data collected for cases in Section A. Personal and cancer details Section A: Non-essential fields

Treatment (in those with known tx,

excluding those reported as none*)

Treatment (in those with tx recorded including those

recorded as none) Index of Multiple

Deprivation

Index of Multiple Deprivation

QARC Region Case n % n % n % All Controls n % East of England 618 474 76.7 496 80.3 602 97.4 1234 139 11.3 East Midlands 660 461 69.8 474 71.8 0 0.0 1310 0 0.0 London 622 373 60.0 434 69.8 90 14.5 1094 328 30.0 North East 425 118 27.8 120 28.2 424 99.8 849 48 5.7 Yorkshire and the Humber 763 301 39.4 306 40.1 732 95.9 1523 130 8.5 North West 831 231 27.8 259 31.2 709 85.3 1660 352 21.2 South Central 495 434 87.7 462 93.3 493 99.6 989 967 97.8 South East Coast 510 387 75.9 401 78.6 492 96.5 1019 956 93.8 South West 762 632 82.9 659 86.5 748 98.2 1523 1503 98.7 West Midlands 822 735 89.4 783 95.3 814 99.0 1640 0 0.0 Total 6508 4146 63.7 4394 67.5 5104 78.4 12841 4423 34.4 *Where treatment was recorded as "None" we assume it means "none other than palliative care". Attempts have been made to clarify this issue and there is now a category for palliative care; however some misclassification may still remain and therefore they are excluded from this column


June 2013

B-1b Proportion of cases with FIGO stage reported as none available, none recorded,* or ‘1B+’ (1B or worse), by QARC region, age, and audit year

QARC Region None

recorded None

available 1B+

(NOS) Total East of England 6.2 0.8 0.7 618 East Midlands 16.4 0.2 0.3 660 London 3.9 0.0 8.4 622 North East 8.9 0.0 17.2 425 Yorkshire and the Humber 21.6 0.1 3.7 763 North West 15.4 0.0 10.7 831 South Central 4.9 1.0 0.2 495 South East Coast 7.5 0.0 2.4 510 South West 1.4 1.3 3.7 762 West Midlands 4.6 5.7 0.0 822 Age <25 10.2 0.8 3.2 127 25-49 7.5 0.3 3.5 4,232 50-64 10.5 1.5 6.2 1,116 65+ 15.4 4.3 6.8 1,033 Audit Year 2009-2010 8.5 1.1 4.2 2452 2010-2011 8.9 1.3 5.0 2,087 2011-2012 10.8 1.1 4.1 1,969 Total 9.3 1.1 4.4 6508 *where stage is reported as none available instead of none recorded a reasonable amount of effort has been made to find the stage, but none has been available. This is derived from cases recorded as "Audit complete" which means that no further details are being sought for these women. The option to report cases as "none available" has only been available to all QARCs since April 2012.


June 2013

B-2 Proportion of data collected for cases in Section B. Cytology

Section B: Cytology

Completeness of data among recorded cytology tests

Total No. of tests

on casesa

Date test was taken Result of Test Action Code

QARC Region Case n % n % n % East of England 618 2,633 2,633 100 2,633 100 2,633 100 East Midlands 660 2,957 2,957 100 2,957 100 2,957 100 London 622 1,443 1,443 100 1,443 100 1,443 100 North East 425 1,675 1,675 100 1,675 100 1,672 100 Yorkshire and the Humber 763 3,230 3,230 100 3,230 100 3,226 99.9 North West 831 3,646 3,646 100 3,646 100 3,642 99.9 South Central 495 2,292 2,292 100 2,292 100 2,281 99.5 South East Coast 510 2,242 2,242 100 2,242 100 2,240 99.9 South West 762 2,995 2,995 100 2,995 100 2,995 100 West Midlands 822 3,506 3,506 100 3,506 100 3,505 100

Total 6508 26,619 26,619 100 26,619 100 26594 99.9 b a Cytology tests known to the Audit and taken before diagnosis

b Cytology data obtained directly from Open Exeter should have all three data fields complete. Missing data, we believe, is the result of inclusion into the audit of cytology tests taken before the programme started in 1988 and a few slides that were found in the laboratory, but not recorded on Exeter. These tests will not have “Action Code” as this field is generated by Exeter.


June 2013

B-3 Proportion of data collected for cases in Section C: Colposcopy Section C: Colposcopy No. of

cases with an Action

Code of suspend

No. of cases with a suspend

and a colposcopy Additional cases

with a colp but no suspend (n)

No. of Colp appts

Date of colp Satisfactory

exam or DNA Colposcopic procedure

QARC Region n % n n % n % n East of England 421 312 74.1 39 516 516 100 515 100 479 East Midlands 456 204 44.7 23 368 368 100 368 100 331 London1 445 439 98.7 166 847 847 100 0 0 360 North East 305 129 42.3 18 214 214 100 214 100 200 Yorkshire and the Humber 570 239 41.9 33 418 418 100 418 100 364 North West 600 262 43.7 27 474 474 100 474 100 423 South Central 346 278 80.3 26 490 490 100 490 100 447 South East Coast 372 266 71.5 19 516 516 100 516 100 440 South West 487 386 79.3 45 751 751 100 751 100 676 West Midlands 521 328 63.0 34 601 601 100 601 100 567 Total 4523 2843 62.9 430 5195 5195 100 4347 83.7 4287 1 London reports the diagnostic sample for every cancer, this has been taken as a colposcopy appointment making the results look complete. However cases very rarely have any other colposcopy recorded


June 2013

APPENDIX CI: LIST OF DATA TABLES

Table 1 Number of invasive cervical cancer cases in 2009–2012 audit, by year and

QARC region 52

Table 2 Number and percentage of invasive cervical cancer cases in five-year age groups, by year of diagnosis

53

Table 3 Number and percentage of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by age

54

Table 4 Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by FIGO stage

55

Table 5 Number of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by FIGO stage

55

Table 5a FIGO stage of invasive cervical cancer cases in 2009–2012: estimated percentage distribution, by QARC region

56

Table 6 Number of invasive cervical cancer cases in 2009–2012 audit, by age and FIGO stage

56

Table 6a FIGO stage of invasive cervical cancer cases in 2009–2012 audit: estimated percentage distribution, by age-group

56

Table 7 Number of invasive cervical cancer cases in 2009–2012 audit, by FIGO stage and year of diagnosis

56

Table 7a FIGO stage of invasive cervical cancer cases: estimated percentage distribution, by year of diagnosis

57

Table 8 Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by histology

57

Table 9 Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by age at diagnosis and histology

57

Table 10 Percentage of invasive cervical cancer cases in 2009–2012 audit, by FIGO stage and histology

58

Table 11 Number of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by treatment

58

Table 11a Percentage of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by treatment

59

Table 12 Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by age at diagnosis and treatment

60

Table 13 Number of invasive cervical cancer cases in 2009–2012 audit, by FIGO stage and treatment

61

Table 13a FIGO stage of invasive cervical cancer cases: estimated percentage distribution in 2009–2012 audit, by treatment

61

Table 14 Cervical screening status of invasive cervical cancer cases and controls under age 65, up to six months prior to diagnosis (percentages)

62

Table 15 Cervical screening status of invasive cervical cancer cases and controls up to six months prior to diagnosis (numbers and percentages), by age

63


June 2013

Table 16 Number and percentage of population controls (GP plus district controls) screened in the 3–5 year interval preceding the date of diagnosis of their matched case, by age

64

Table 16a Number and percentage of population controls (GP plus district controls) screened in the 3–5 year interval preceding the date of diagnosis of their matched case (aged 25–64), by QARC region

65

Table 17 Time to previous cytology test among screened controls 66 Table 17a Time to previous cytology test among potentially screen-detected cases of

cervical cancer and their screened controls 67

Table 18 Maximum interval between cytology tests (over the previous 8 years) among cases with FIGO stage 1B+ and their population controls

68

Table 19

Number and percentage of invasive cervical cancer cases in 2009–2012 audit with colposcopic appointment recorded, by QARC region

69

Table 20 Original cytology result by review result 70


June 2013

APPENDIX CII: DATA TABLES

Table 1. Number of cases of invasive cervical cancer, 2009-2012, by audit year* and QARC Year QARC Region 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012 T East of England 182 217 217 211 190 1 East Midlands 200 195 233 219 208 1 London 237 231 278 212 132 1 North East 134 160 170 125 130 7 Yorkshire and the Humber 268 244 271 236 256 1 North West 314 298 324 271 236 1 South Central 170 164 187 162 146 8 South East Coast 145 158 195 160 155 8 South West 262 288 285 249 228 1 West Midlands 246 299 292 242 288 1 Total 2158 2254 2452 2087 1969 10 *Audit year between 1 April and the 31 March


June 2013

Table 2. Number and percentage of invasive cervical cancer in 2009-2012 audit in five-year age groups, by year of diagnosis

Audit Year1 <202 20-24 25-29 30-34 35-39 40-44 45-49 50-55 55-59 60-64 65-69 70-74 75-79 80+ 2009-2010 0 52 392 367 358 299 211 138 127 121 89 90 74 134 2010-2011 0 45 320 270 279 252 193 142 125 120 91 64 70 116 2011-2012 1 29 325 251 250 268 197 122 115 106 67 59 78 101

Total 1 126 1037 888 887 819 601 402 367 347 247 213 222 351 Percent

2009-2010 0.0 2.1 16.0 15.0 14.6 12.2 8.6 5.6 5.2 4.9 3.6 3.7 3.0 5.5 2010-2011 0.0 2.2 15.3 12.9 13.4 12.1 9.2 6.8 6.0 5.7 4.4 3.1 3.4 5.6 2011-2012 0.1 1.5 16.5 12.7 12.7 13.6 10.0 6.2 5.8 5.4 3.4 3.0 4.0 5.1

Total 0.0 1.9 15.9 13.6 13.6 12.6 9.2 6.2 5.6 5.3 3.8 3.3 3.4 5.4 1Audit year runs 1 April to 31 March 2 Case 19.5 yrs old


June 2013

Table 3. Number and percentage of invasive cervical cancer cases in 2009-2012 audit for each QARC region, by age QARC Region <25 25-49 50-64 65+ Total East of England 10 379 126 103 618 East Midlands 17 460 86 97 660 London 14 403 118 87 622 North East 10 277 80 58 425 Yorkshire and the Humber 13 526 129 95 763 North West 22 552 131 126 831 South Central 6 331 78 80 495 South East Coast 9 343 90 68 510 South West 18 464 125 155 762 West Midlands 8 497 153 164 822

Total 127 4232 1116 1033 6508 Percent

East of England 1.6 61.3 20.4 16.7 100 East Midlands 2.6 69.7 13.0 14.7 100 London 2.3 64.8 19.0 14.0 100 North East 2.4 65.2 18.8 13.6 100 Yorkshire and the Humber 1.7 68.9 16.9 12.5 100 North West 2.6 66.4 15.8 15.2 100 South Central 1.2 66.9 15.8 16.2 100 South East Coast 1.8 67.3 17.6 13.3 100 South West 2.4 60.9 16.4 20.3 100 West Midlands 1.0 60.5 18.6 20.0 100

Total 2.0 65.0 17.1 15.9 100


June 2013

Table 4. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage* FIGO Stage Number Percentage 1A NOS 874 13.4 1A1 1,186 18.2 1A2 107 1.6 1B+ NOS 289 4.4 1B NOS 947 14.6 1B1 834 12.8 1B2 115 1.8 2 NOS 40 0.6 2A 124 1.9 2B 606 9.3 3 NOS 67 1.0 3A 60 0.9 3B 249 3.8 4 NOS 142 2.2 4A 91 1.4 4B 96 1.5 None available 69 1.1 None recorded 612 9.4 Total 6508 100 *NOS= not otherwise specified (or not further specified)

Table 5. Number of invasive cervical cancer cases in 2009-2012 audit for each QARC region, by FIGO stage

QARC Region 1A 1B 2 3 4 1B+ None

recorded Total East of England 196 205 86 44 40 4 43 618 East Midlands 241 197 61 25 25 2 109 660 London 202 162 94 51 37 52 24 622 North East 139 124 30 12 9 73 38 425 Yorkshire and the Humber 318 184 31 21 15 28 166 763 North West 259 252 50 31 22 89 128 831 South Central 178 153 61 39 34 1 29 495 South East Coast 180 164 66 28 22 12 38 510 South West 239 239 123 56 56 28 21 762 West Midlands 215 216 168 69 69 0 85 822 Total 2167 1896 770 376 329 289 681 6508


June 2013

Table 5a. FIGO stage of invasive cervical cancer cases in 2009-2012: estimated percent distribution, by QARC region

QARC Region 1A 1B 2+ Total East of England 32.5% 36.9% 30.6% 100 East Midlands 38.0% 32.0% 30.0% 100 London 35.0% 27.2% 37.8% 100 North East 36.3% 34.2% 29.5% 100 Yorkshire and the Humber 44.8% 30.1% 25.1% 100 North West 33.3% 36.9% 29.9% 100 South Central 36.4% 32.1% 31.5% 100 South East Coast 36.9% 35.3% 27.8% 100 South West 32.4% 32.8% 34.8% 100 West Midlands 26.9% 28.2% 44.9% 100 England 35.0% 32.4% 32.6% 100

Table 6. Number of invasive cervical cancer cases in 2009-2012 audit, by age and FIGO stage

Age 1A 1B 2 3 4 1B+(NOS) None

Recorded Total <25 37 47 16 6 3 4 14 127 25-49 1,900 1,322 337 116 81 146 330 4232 50-64 184 324 202 107 96 69 134 1116 65+ 46 203 215 147 149 70 203 1033 Total 2167 1896 770 376 329 289 681 6508

Table 6a. FIGO stage of invasive cervical cancer cases in 2009–2012 audit: estimated percentage distribution, by age-group Age 1A 1B 2 Total Total <25 31.8 42.3 25.8 100 127 25-49 46.8 34.3 18.8 100 4232 50-64 17.9 32.2 49.9 100 1116 65+ 5.4 23.8 70.8 100 1033 All ages 35.0 32.4 32.6 100 6508

Table 7. Number of invasive cervical cancer cases in 2009-2012 audit, by FIGO stage and year of diagnosis

Year 1A 1B 2 3 4 1B+(NOS) None

Recorded Total 2009-2010 826 735 284 147 121 103 236 2,452 2010-2011 674 586 285 126 99 105 212 2,087 2011-2012 667 575 201 103 109 81 233 1,969 Total 2167 1896 770 376 329 289 681 6508


June 2013

Table 7a. FIGO stage of invasive cervical cancer cases: estimated percentage distribution, by year of diagnosis

Year 1A 1B 2 Total 2009-2010 35.8 33.6 30.7 100 2010-2011 33.9 31.4 34.7 100 2011-2012 35.2 32.1 32.7 100 Total 35.0 32.4 32.6 100

Table 8. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by histology

Year Squamous Adenocarcinoma Adeno-

Squamous Undifferentiated Other None

recorded 2009-2010 1,748 492 72 15 35 90 2010-2011 1,518 384 58 6 46 75 2011-2012 1,415 390 53 13 34 64

Total 4681 1266 183 34 115 229 Percent

2009-2010 71.3 20.1 2.9 0.6 1.4 3.7 2010-2011 72.7 18.4 2.8 0.3 2.2 3.6 2011-2012 71.9 19.8 2.7 0.7 1.7 3.3

Total 71.9 19.5 2.8 0.5 1.8 3.5

Table 9. Number and percentage of invasive cervical cancer cases in 2009-2012 audit, by age at diagnosis and histology

Age Squamous Adenocarcinoma Adeno-

Squamous

Other (incl

undifferentiated) None

recorded Total <25 92 21 4 8 2 127 25-49 3074 838 121 68 131 4232 50-64 795 227 33 24 37 1116 65+ 720 180 25 49 59 1033

Total 4681 1266 183 149 229 6508 Percent

<25 72.4 16.5 3.1 6.3 1.6 100 25-49 72.6 19.8 2.9 1.6 3.1 100 50-64 71.2 20.3 3.0 2.2 3.3 100 65+ 69.7 17.4 2.4 4.7 5.7 100

All ages 71.9 19.5 2.8 2.3 3.5 100


June 2013

Table 10. Percentage of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage and histology

Stage Squamous Adenocarcinoma Adeno-

Squamous Other (incl

undifferentiated) None

recorded Total 1A 38.3 23.4 7.7 8.7 21.4 33.3 1B+ 52.9 65.2 84.2 70.5 41.9 56.2 None recorded 8.7 11.4 8.2 20.8 36.7 10.5

Total 100 100 100 100 100 100

Table 11. Number of invasive cervical cancer in 2009-2012 audit for each QARC region, by treatment

QARC Region

Non

e

Con

e bi

opsy

/ Loo

p ex

cisi

on

Trac

hale

ctom

y

Sim

ple

hyst

erec

tom

y

Rad

ical

hy

ster

ecto

my

Hys

tere

ctom

y/R

adio

ther

apy

Hys

tere

ctom

y/ch

emot

hera

py

Hys

tere

ctom

y/R

adio

/Che

mo

Rad

ioth

erap

y

Che

mot

hera

py

Rad

ioth

earp

y/

Che

mot

hera

py

Palli

ativ

e ca

re

Oth

er

Non

e re

cord

ed

Tota

l

East of England 22 150 20 31 97 5 4 13 21 12 120 1 0 122 618 East Midlands 13 137 5 50 105 4 1 7 36 12 104 0 0 186 660 London 61 80 16 36 68 5 2 3 37 15 96 0 15 188 622 North East 2 38 2 8 33 1 0 1 7 3 25 0 0 305 425 Yorkshire and the Humber 5 113 3 21 54 7 0 5 18 7 73 0 0 457 763 North West 28 129 4 14 37 2 1 2 16 2 24 0 0 572 831 South Central 28 179 8 21 72 10 4 11 21 11 96 1 0 33 495 South East Coast 14 172 6 30 74 3 0 10 22 10 60 0 0 109 510 South West 27 177 20 46 135 9 1 18 51 17 158 0 0 103 762 West Midlands 48 154 20 142 51 10 6 46 58 27 215 6 0 39 822 Total 248 1329 104 399 726 56 19 116 287 116 971 8 15 2114 6508


June 2013

Table 11a. Percentage of invasive cervical cancer cases in 2009–2012 audit for each QARC region, by treatment

QARC Region

Non

e

Con

e bi

opsy

/ Loo

p ex

cisi

on

Trac

hale

ctom

y

Sim

ple

hyst

erec

tom

y

Rad

ical

hy

ster

ecto

my

Hys

tere

ctom

y/R

adi

othe

rapy

Hys

tere

ctom

y/ch

emot

hera

py

Hys

tere

ctom

y/R

adi

o/ C

hem

o

Rad

ioth

erap

y

Che

mot

hera

py

Rad

ioth

earp

y/

Che

mot

hera

py

Palli

ativ

e ca

re

Oth

er

Non

e re

cord

ed

Tota

l

East of England 3.6 24.3 3.2 5.0 15.7 0.8 0.6 2.1 3.4 1.9 19.4 0.2 0.0 19.7 100 East Midlands 2.0 20.8 0.8 7.6 15.9 0.6 0.2 1.1 5.5 1.8 15.8 0.0 0.0 28.2 100 London 9.8 12.9 2.6 5.8 10.9 0.8 0.3 0.5 5.9 2.4 15.4 0.0 2.4 30.2 100 North East 0.5 8.9 0.5 1.9 7.8 0.2 0.0 0.2 1.6 0.7 5.9 0.0 0.0 71.8 100 Yorkshire and the Humber 0.7 14.8 0.4 2.8 7.1 0.9 0.0 0.7 2.4 0.9 9.6 0.0 0.0 59.9 100 North West 3.4 15.5 0.5 1.7 4.5 0.2 0.1 0.2 1.9 0.2 2.9 0.0 0.0 68.8 100 South Central 5.7 36.2 1.6 4.2 14.5 2.0 0.8 2.2 4.2 2.2 19.4 0.2 0.0 6.7 100 South East Coast 2.7 33.7 1.2 5.9 14.5 0.6 0.0 2.0 4.3 2.0 11.8 0.0 0.0 21.4 100 South West 3.5 23.2 2.6 6.0 17.7 1.2 0.1 2.4 6.7 2.2 20.7 0.0 0.0 13.5 100 West Midlands 5.8 18.7 2.4 17.3 6.2 1.2 0.7 5.6 7.1 3.3 26.2 0.7 0.0 4.7 100 Total 3.8 20.4 1.6 6.1 11.2 0.9 0.3 1.8 4.4 1.8 14.9 0.1 0.2 32.5 100


June 2013

Table 12. Number and percentage of invasive cervical cancer cases in 2009–2012 audit, by age at diagnosis and treatment

Treatment <50 50-64 65-79 80+ Total None(palliative) 73 53 60 70 256 Cone biopsy/ Loop excision 1231 79 13 6 1329 Trachelectomy 103 0 0 1 104 Hysterectomy only (simple or radical) 856 206 47 16 1125 Radiotherapy (+/- hysterectomy) 80 64 103 96 343 Chemotherapy (+/- hysterectomy) 55 42 32 6 135 Chemo-radiotherapy (+/- hysterectomy) 567 316 180 24 1087 Not recorded (Other) 1394 356 247 132 2129

Total 4359 1116 682 351 6508 Percent

None(palliative) 1.7 4.7 8.8 19.9 3.9 Cone biopsy/ Loop excision 28.2 7.1 1.9 1.7 20.4 Trachelectomy 2.4 0.0 0.0 0.3 1.6 Hysterectomy only (simple or radical) 19.6 18.5 6.9 4.6 17.3 Radiotherapy (+/- hysterectomy) 1.8 5.7 15.1 27.4 5.3 Chemotherapy (+/- hysterectomy) 1.3 3.8 4.7 1.7 2.1 Chemo-radiotherapy (+/- hysterectomy) 13.0 28.3 26.4 6.8 16.7 Not recorded (Other) 32.0 31.9 36.2 37.6 32.7

Total 100 100 100 100 100


June 2013

Table 13. Number of invasive cervical cancer cases in 2009-2012 audit, by FIGO Stage and treatment

Treatment 1A 1B 2 3 4 1B+(NOS) None

recorded Total None(palliative) 34 39 24 35 62 18 44 256 Cone biopsy/ Loop excision 1078 180 12 1 5 10 43 1329 Trachelectomy 14 83 3 0 0 2 2 104 Hysterectomy 343 680 36 10 3 17 36 1125 Radiotherapy (+/- hyst) 8 78 91 71 56 8 31 343 Chemotherapy (+/- hyst) 6 28 27 25 35 4 10 135 Radiotherapy/Chemotherapy (+/- hyst) 20 260 444 172 99 33 59 1087 Not recorded(Other) 664 548 133 62 69 197 456 2129 Total 2167 1896 770 376 329 289 681 6508

Table 13a. FIGO stage of invasive cervical cancer cases: estimated percentage distribution in 2009–2012 audit, by treatment

Treatment 1A 1B 2 Total None(palliative) 13.8 20.4 65.7 100 Cone biopsy/ Loop excision 83.3 15.0 1.8 100 Trachelectomy 13.5 83.7 2.9 100 Hysterectomy 31.5 63.6 5.0 100 Radiotherapy (+/- hyst) 2.5 24.3 73.2 100 Chemotherapy (+/- hyst) 4.6 21.8 73.6 100 Radiotherapy/Chemotherapy (+/- hyst) 1.9 25.6 72.5 100 Not recorded (Other) 34.4 31.3 34.3 100 Total 35.0 32.4 32.6 100


June 2013

Table 14. Cervical screening status of invasive cervical cancer cases and controls aged 25-64, up to six months prior to diagnosis (percentages)

Cervical screening status up to six months prior to diagnosis

Population Controls Cases Stage 1A Cases Stage 1B+

Cases Stage not recorded

N % N % N % N %

No cytology test (except within 6 months of diagnosis) 1,379 13.3 570 27.4 735 26.3 128 27.6 Last smear routine and

Up to date 6,305 60.9 405 19.4 678 24.2 125 26.9 Lapsed 1,702 16.4 567 27.2 790 28.2 121 26.1 Last smear early repeat

Up to date 455 4.4 152 7.3 141 5.0 21 4.5 Lapsed 369 3.6 144 6.9 245 8.8 34 7.3

Last smear suspend (not followed by any negative(s)) 76 0.7 231 11.1 190 6.8 32 6.9

Last smear suspend (followed by at least one negative) 73 0.7 15 0.7 21 0.8 3 0.6 Total 10,359 100 2084 100 2800 100 464 100

We have used the action code provided by Exeter to determine whether the last cytology test lead to a routine recall, early recall or suspend from the recall programme. After a routine recall interval we consider the screening to be up to date when the diagnosis occurred within 3.5 years (or 5.5 years for older women) from the routine cytology test. After an action code of early repeat we consider the screening to be up to date when the diagnosis occurred within 1.25 years (or .25 years if the test was inadequate) of the early repeat test. When the last test (six month before diagnosis) was suspend and was followed by at least one negative test, women were up to date if the diagnosis was made within 1.5 years of the test leading to the suspend code. Those that were suspended more than 6 months before diagnosis and are not followed by any negative tests are considered to be lapsed.


June 2013

Table 15. Cervical screening status of invasive cervical cancer cases and controls up to six months prior to diagnosis (numbers and percentages), by age

Cervical screening status up to six months prior to diagnosis

All Cases Controls 20-24 25-49 50-64 65-79 80+ 20-24 20-49 50-64 65-79 80+

No cytology test (except within six months of diagnosis) 114 1,125 308 238 217 393 1,260 119 177 387 Last smear routine and

Up to date 4 888 320 271 114 22 4,711 1,594 957 295 Lapsed 1 1,217 261 99 5 9 1,338 364 158 5

Last smear early repeat and

Up to date 4 275 39 6 6 6 415 40 4 5

Lapsed 0 328 95 50 8 1 313 56 42 9

Last smear suspend* 3 399 93 18 1 1 130 19 4 2 Total 126 4,232 1,116 682 351 432 8,167 2,192 1,342 703

Percent

No cytology test (except within six months of

diagnosis) 90.5 26.6 27.6 34.9 61.8 91.0 15.4 5.4 13.2 55.0 Last smear routine and

Up to date 3.2 21.0 28.7 39.7 32.5 5.1 57.7 72.7 71.3 42.0 Lapsed 0.8 28.8 23.4 14.5 1.4 2.1 16.4 16.6 11.8 0.7

Last smear early repeat and

Up to date 3.2 6.5 3.5 0.9 1.7 1.4 5.1 1.8 0.3 0.7

Lapsed 0.0 7.8 8.5 7.3 2.3 0.2 3.8 2.6 3.1 1.3

Last smear suspend* 2.4 9.4 8.3 2.6 0.3 0.2 1.6 0.9 0.3 0.3 Total 100 100 100 100 100 100 100 100 100 100

* The categories "last smear suspend (not followed by any negative)" and "last smear suspend (followed by al least one negative)" found in table 14 are combined due to small numbers


June 2013

Table 16. Number and percentage of population controls (GP plus district controls) screened in the 3-5 year interval preceding the date of diagnosis of their matched case, by age

Age Total

Not screened in

previous interval

Screened once in

previous interval

Screened twice in previous interval

Screened ≥3 times

in previous interval

20-24

437 394 32 5 6 25-29

1880 735 966 87 92

30-34

1730 552 977 94 107 35-39

1745 505 1074 93 73

40-44

1629 424 1078 60 67 45-49

1183 334 779 37 33

50-54

798 152 381 226 39 55-59

724 180 487 37 20

60-64

670 188 452 20 10 65-69

482 112 285 74 11

70-74

419 105 203 88 23 75-79

441 144 184 98 15

80+

703 404 212 75 12 Total 12841 4229 7110 994 508

Percent National Coverage reported in 2011/12*

Coverage (>=1 test in interval) % % % %

20-24 3.6 9.8† 90.2 7.3 1.1 1.4 25-29 63.0 60.9 39.1 51.4 4.6 4.9 30-34 72.7 68.1 31.9 56.5 5.4 6.2 35-39 76.1 71.1 28.9 61.5 5.3 4.2 40-44 78.1 74.0 26.0 66.2 3.7 4.1 45-49 78.3 71.8 28.2 65.8 3.1 2.8 50-54 82.8 81.0 19.0 47.7 28.3 4.9 55-59 76.6 75.1 24.9 67.3 5.1 2.8 60-64 72.7 71.9 28.1 67.5 3.0 1.5 65-69 - 76.8 23.2 59.1 15.4 2.3 70-74 - 74.9 25.1 48.4 21.0 5.5 75-79 - 67.3 32.7 41.7 22.2 3.4 80+ - 42.5 57.5 30.2 10.7 1.7

Total 32.9 55.4 7.7 4.0 * Source: NHS Cervical Screening Programme in England in 2011-11. Note: we have used the 3 yearly coverage for women aged 20-49 and the 5 yearly coverage for women aged 50-64 using table 2 (see reference 9)

† Note: 71.8% of controls aged 20-24 are aged 24, only 4.5% are aged 20 or 21. Thus this age group is a reflection of the age at which their matched cases were diagnosed and not of the distribution of women aged 20-24 nationally. This explains the difference in coverage nationally and in the audit.


June 2013

Table 16a. Number and percentage of population controls (GP plus district controls) screened in the 3-5 year interval preceding the date of diagnosis of their matched case ( aged 25-64), by QARC region

QARC Total

Not screened in previous interval

Screened once in previous interval

Screened twice in previous interval

Screened ≥3 times in previous interval

East of England 989 250 623 70 46 East Midlands 1054 292 662 50 50 London 909 304 501 67 37 North East 690 203 410 48 29 Yorkshire and the Humber 1277 387 774 70 46 North West 1352 405 790 92 65 South Central 812 250 468 65 29 South East Coast 848 269 497 49 33 South West 1159 330 710 71 48 West Midlands 1269 380 759 72 58

Total 10359 3070 6194 654 441

Percent

Coverage (>=1 test in

interval) East of England 74.7 25.3 63.0 7.1 4.7

East Midlands 72.3 27.7 62.8 4.7 4.7 London 66.6 33.4 55.1 7.4 4.1 North East 70.6 29.4 59.4 7.0 4.2 Yorkshire and the Humber 69.7 30.3 60.6 5.5 3.6 North West 70.0 30.0 58.4 6.8 4.8 South Central 69.2 30.8 57.6 8.0 3.6 South East Coast 68.3 31.7 58.6 5.8 3.9 South West 71.5 28.5 61.3 6.1 4.1 West Midlands 70.1 29.9 59.8 5.7 4.6

Total 29.6 59.8 6.3 4.3


June 2013

Table 17. Time to previous cytology among screened controls Time to previous screen

Age <2.75 yrs

2.75-3.5 yrs

3.5-4.75 yrs

4.75-5.5 yrs

5.5-9.5 yrs

No previous cytology within 9.5

years Total 25-29 13 105 32 20 42 385 597 30-34 11 162 70 27 52 101 423 35-39 15 164 53 23 51 55 361 40-44 8 178 38 20 32 24 300 45-49 7 122 28 5 20 10 192 50-54 6 50 16 5 10 11 98 55-59 2 4 3 58 13 5 85 60-64 0 4 9 41 6 12 72

Total 62 789 249 199 226 603 2128 Percent

25-29 2.2 17.6 5.4 3.4 7.0 64.5 100 30-34 2.6 38.3 16.5 6.4 12.3 23.9 100 35-39 4.2 45.4 14.7 6.4 14.1 15.2 100 40-44 2.7 59.3 12.7 6.7 10.7 8.0 100 45-49 3.6 63.5 14.6 2.6 10.4 5.2 100 50-54 6.1 51.0 16.3 5.1 10.2 11.2 100 55-59 2.4 4.7 3.5 68.2 15.3 5.9 100 60-64 0.0 5.6 12.5 56.9 8.3 16.7 100

Total 2.9 37.1 11.7 9.4 10.6 28.3 100


June 2013

Table 17a. Time to previous cytology test among potentially screen-detected* cases of cervical cancer and their screened controls Time to previous screen

Age <3.5 yrs 3.5-4.75 yrs 4.75-5.5 yrs 5.5-9.5 yrs

No previous cytology within

9.5 yrs Total <5.5 yrs

Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls

25-34 226 291 96 102 43 47 121 94 546 486 1032 1020 365 440 35-49 296 464 88 119 38 48 131 103 298 89 851 853 422 631 50-64 28 66 17 28 54 104 24 29 130 28 253 255 99 198

Total 550 821 201 249 135 199 276 226 974 603 2136 2128 886 1269 Percent

Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls 25-34 21.9 28.5 9.3 10.0 4.2 4.6 11.7 9.2 52.9 47.6 100 100 35.4 43.1 35-49 34.8 54.4 10.3 14.0 4.5 5.6 15.4 12.1 35.0 10.4 100 100 49.6 74.0 50-64 11.1 25.9 6.7 11.0 21.3 40.8 9.5 11.4 51.4 11.0 100 100 39.1 77.6

Total 25.7 38.6 9.4 11.7 6.3 9.4 12.9 10.6 45.6 28.3 100 100 41.5 59.6 *A potentially screen-detected case is one in which cytology results are consistent with screen detection; there is no national record of whether the cytology was in response to screening or to symptoms


June 2013

Table 18. Maximum interval between cytology tests (over the previous 8 years) among cases with FIGO stage 1B+ and their population controls Maximum Interval between cytology tests

Age <3.5 yrs 3.5-4.75 yrs 4.75-5.5 yrs 5.5-7yrs >7 yrs or no

cytology Total

Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls Cases Controls

28-34 92 344 112 249 54 111 63 151 246 268 567 1123 35-49 251 1058 225 626 86 213 139 250 596 400 1297 2547 50-64 87 354 106 481 99 301 48 151 458 264 798 1551

Total 430 1756 443 1356 239 625 250 552 1300 932 2662 5221 Percent

28-34 16.2 30.6 19.8 22.2 9.5 9.9 11.1 13.4 43.4 23.9 100 100 35-49 19.4 41.5 17.3 24.6 6.6 8.4 10.7 9.8 46.0 15.7 100 100 50-64 10.9 22.8 13.3 31.0 12.4 19.4 6.0 9.7 57.4 17.0 100 100

Total 16.2 33.6 16.6 26.0 9.0 12.0 9.4 10.6 48.8 17.9 100 100


June 2013

Table 19. Number and percentage of invasive cervical cancer cases in 2009-2012 audit with colposcopic appointment recorded, by QARC region

QARC region Number of cases

Cases with a recorded

colposcopy

Cases with an action code "suspend"

Cases with a "suspend" code

>4 months before diagnosis

Cases with "Suspend" >4 months before

diagnosis + colposcopy

Cases with "Suspend" >4 months before

diagnosis + colposcopy (excluding colposcopy

within 2 months of diagnosis)

n % n % n % n % n %

East of England 618 351 56.8 421 68.1 104 16.8 73 70.2 49 47.1 East Midlands 660 227 34.4 456 69.1 119 18.0 61 51.3 31 26.1 London 622 605 97.3 445 71.5 126 20.3 125 99.2 60 47.6 North East 425 147 34.6 305 71.8 56 13.2 23 41.1 17 30.4 Yorkshire and the Humber 763 272 35.6 570 74.7 145 19.0 68 46.9 40 27.6 North West 831 289 34.8 600 72.2 193 23.2 80 41.5 52 26.9 South Central 495 304 61.4 346 69.9 76 15.4 63 82.9 47 61.8 South East Coast 510 285 55.9 372 72.9 91 17.8 59 64.8 43 47.3 South West 762 431 56.6 487 63.9 140 18.4 105 75.0 76 54.3 West Midlands 822 362 44.0 521 63.4 149 18.1 86 57.7 60 40.3 Total 6508 3273 50.3 4523 69.5 1199 18.4 743 62.0 475 39.6


June 2013

Table 20. Original cytology result by review result1

Original result

Review Result Negative Inadequate Borderline Low-grade

(mild) Low-grade

(Mod) High-grade

(severe) ?Invasive ?Glandular Total

N % N % N % N % N % N % N % N % N % Negative 2,800 51.1 506 9.2 997 18.2 135 2.5 181 3.3 572 10.4 29 0.5 260 4.7 5,480 100 Inadequate 58 8.2 417 59.1 93 13.2 15 2.1 12 1.7 72 10.2 11 1.6 27 3.8 705 100 Borderline 22 2.3 10 1.0 424 43.4 69 7.1 64 6.6 234 24.0 20 2.0 134 13.7 977 100 Low-grade (mild)

4 1.1 1 0.3 35 9.5 152 41.3 78 21.2 88 23.9 5 1.4 5 1.4 368 100

High-grade (moderate)

1 0.2 0 0.0 6 1.5 4 1.0 138 33.9 229 56.3 19 4.7 10 2.5 407 100

High-grade (severe)

9 0.4 3 0.1 5 0.2 0 0.0 9 0.4 1,788 85.1 204 9.7 84 4.0 2,102 100

?Invasive 1 0.1 0 0.0 0 0.0 0 0.0 1 0.1 41 6.1 621 91.9 12 1.8 676 100 ?Glandular 2 0.4 0 0.0 3 0.6 0 0.0 0 0.0 30 5.7 13 2.5 479 90.9 527 100 Total 2,897 25.8 937 8.3 1,563 13.9 375 3.3 483 4.3 3,054 27.2 922 8.2 1,011 9.0 11,242 100 1 Updated version of Table 1 in Castanon et al14

NHSCSP AUDIT OF INVASIVE CERVICAL CANCER: NATIONAL … · 2019-10-03 · cancer (an estimated 9% of...

Documents

Transcript of NHSCSP AUDIT OF INVASIVE CERVICAL CANCER: NATIONAL … · 2019-10-03 · cancer (an estimated 9% of...